Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

Pulmonary Nocardiosis Presenting as Endobronchial Mass in an Immunocompetent Host FREE TO VIEW

Rachel Guthrie, DO; David Rudinsky, DO
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OhioHealth Riverside Methodist Hospital, Columbus, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):182A. doi:10.1016/j.chest.2016.08.191
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION:Nocardia is a weakly acid fast, filamentous, gram-positive bacillus found in soil worldwide. Although typically an opportunistic infection, up to 1/3 of patients with Nocardiosis are immunocompetent. Nocardiosis most commonly presents as pulmonary disease via inhalation exposure. We present a case of Nocardia beijingensis in an immunocompetent host manifesting as an endobronchial mass with progression to disseminated CNS disease.

CASE PRESENTATION: 59 year old male with prior tobacco abuse, presented with two months of progressive dyspnea, cough, and fevers despite antibiotics. CT demonstrated a mediastinal mass with compression of the left mainstem bronchus, mediastinal lymphadenopathy, and cavitary consolidation of the left lower lobe. A necrotic endobronchial mass causing 80% obstruction of left mainstem bronchus was visualized on bronchoscopy. Biopsies revealed inflammation without evidence of malignancy. Bronchial cultures and cytology were initially unremarkable. Diagnostic endobronchial ultrasound and fine needle aspiration of mediastinal lymph nodes revealed granulation tissue with suppuration. HIV, tuberculous, and fungal serologies were negative. Patient was discharged home, but represented sixteen days later for headache and confusion. Original bronchial cultures now showed light growth of Nocardia, and cerebral imaging was consistent with intracranial abscesses. Emergent craniotomy and abscess drainage revealed frank purulence and intraoperative cultures were also positive for Nocardia beijingensis. He was treated with IV trimethoprim-sulfamethoxazole (TMP-SMX) and IV meropenem for 8 weeks, followed by oral TMP-SMX monotherapy for 12 months. Chest and brain imaging one year later showed no evidence of recurrent disease.

DISCUSSION: Nocardiosis presents with various clinical and radiographic manifestations that may mimic malignancy or common pulmonary infections such as tuberculosis, actinomyces, or aspergillosis, making diagnosis difficult. Furthermore, slow growth of Nocardia can lead to delay in treatment. Common CT findings of pulmonary nocardiosis include pulmonary nodules, consolidation, cavitation, pleural involvement, or ground glass opacities, and typically lacks mediastinal lymphadenopathy. Although nocardiosis is rare in an immunocompetent host, it is important to keep in the differential.

CONCLUSIONS: This case highlights an atypical radiographic and bronchoscopic presentation of pulmonary nocardiosis, reinforcing the importance of bronchoscopy evaluation for inspection, cultures, and tissue biopsy. Furthermore, it is important that the bronchoscopist be mindful of the slow growth of Nocardia, the importance of culture follow up, and the impact on delayed diagnosis and treatment.

Reference #1: Wilson JW. Nocardiosis: Updates and Clinical Overview. Mayo Clinic Proc. 2012;87(4):403-407.

Reference #2: Kanne JP et al. CT findings of Pulmonary Nocardiosis. American Journal of Roentgenology 2011;197:W266-W272.

DISCLOSURE: The following authors have nothing to disclose: Rachel Guthrie, David Rudinsky

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