Case of coexisting Nocardia cyriacigeorgica and Aspergillus fumigatus lung infection with metastatic disease of the central nervous system

Abstract

Nocardiosis is a rare opportunistic gram-positive bacterial infection. The genus Nocardia consists of non-motile, aerobic, non-spore-forming, catalase-positive, filamentous-branching bacteria with fragmentation into coccoid or bacillary forms. Opportunistic infections due to Nocardia are reported in immunocompromised patients. Aspergillus fumigatus is a conidia forming fungus that can be found in soil, plant matter and dust, causing invasive pulmonary and disseminated infection in immunocompromised patients. Both Nocardia cyriacigeorgica and A. fumigatus are known to cause pulmonary infection with metastatic dissemination to the central nervous system. We present a case of Nocardia and Aspergillus co-infection in a patient who presented within a few days of initiation of immunosuppressants for suspected systemic lupus erythematosus.

Keywords: TB and other respiratory infections; drugs: infectious diseases.

Figure 1

Grocott-Gomori methenamine silver (GMS) stain of bronchoalveolar lavage at 500× magnification showing thin branching filaments of Nocardia (upward arrow) and Aspergillus on GMS stain with hyphae branching at 45 degree (right arrow).

Figure 2

(A) Chest X-ray PA view on presentation showing multiple foci of consolidation in bilateral lung most prominent in right lower lobe (marked by star) and follow-up chest X-ray with resolution of consolidation. (B) MRI of the brain showing rim-enhancing lesions within the brain (marked right arrows) and follow-up MRI showing resolution after medical treatment.