A 36‐year‐old white woman presented with cough, wheezing, shortness of breath, and fever of 3 weeks' duration. She smoked daily but had no history of chronic obstructive pulmonary disease. She was initially evaluated in the emergency department earlier that day and treated with azithromycin and oral steroids. Shortness of breath worsened, however, and she was admitted. On examination, she was in respiratory distress, wheezing, hypoxic on room air, febrile, and tachycardic. She had bilateral rhonchi. Other exams were normal. White cell count was normal. Chest x‐ray showed prominence of the perihilar bronchial markings and peribronchial markings suggesting early pneumonitis. She was commenced on levofloxacin, steroids, and beta‐agonist nebulizers. CT of the chest showed several small patchy infiltrates in the peripheral lung field. There was transient improvement in her symptoms but she got worse on day 4 of admission. Repeat CT chest done after 1 week of admission showed worsening infiltrate with numerous rounded fuzzy ground‐glass infiltrate with bronchogram. Bronchoscopy was done and bronchial alveoli lavage grew Aspergillus fumigatus and a pleomorphic gram‐positive bacilli. Her IgE was normal, Aspergillus IgG and IgM were negative, HIV serology was negative; ANCA and ANA were also negative. She had not been on steroids prior to this admission. She was subsequently commenced on voriconazole. She improved and was discharged on voriconazole, tapering dose of steroids, and oxygen. The gram‐positive bacillus was later identified as Norcardia cyriageorgica, which was sensitive to Bactrim. She was commenced on Bactrim. CT chest done 3 months later showed improvement in the infiltrates. She improved and was weaned off oxygen but continued to have residual reactive airway.
Aspergillus lung infection could present in 3 forms, (1) reactive airways disease, (2) an invasive fungal ball, (3) as pneumonia. Pulmonary nocardiosis is a rare disorder that mainly affects immunocompromised patients. Several risk factors have been identified, such as corticosteroid therapy, chronic obstructive pulmonary disease (COPD), cystic fibrosis, and bronchiectasis. Diagnosis of nocardiosis is difficult as bacteriological culture can be problematic. Coinfection with Aspergillus and Nocardia is rare and has been reported mainly in immunocompromised state. This is the second case reported in an immunocompetent host. Patients typically require long‐term treatment for resolution of these infections.
Identification of the atypical presentation and clinical course was key in making this diagnosis. Pulmonary aspergillosis and nocardiosis should be considered in the differential diagnosis of an immunocompetent patient who presents with pneumonia not responsive to conventional antibiotics.
To cite this abstract:Ugbarugba E. A Case of Aspergillus and Norcardia Lung Infection in an Immunocompetent Patient. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 335. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-aspergillus-and-norcardia-lung-infection-in-an-immunocompetent-patient/. Accessed April 10, 2020.