Case history
Case history
A 29-year-old man presents with a one-month history of productive cough, weakness, malaise, fever, and weight loss. His social history is significant for heavy smoking, high alcohol intake, multiple sexual partners, and use of intravenous drugs with sharing of needles. He is HIV-positive and is not engaged in medical care. He is not taking any medication. Physical examination shows signs of malnutrition; bilateral, diffuse rales; oral thrush; a subcutaneous abscess on the left leg with purulent secretion; and perineal condylomas. The rest of the examination is unremarkable.
Other presentations
Pulmonary nocardiosis can present clinically with acute, subacute, or chronic pneumonia. The radiographic patterns include lobar infiltrates, abscesses, cavities, or pleural effusions that may represent an empyema. Thus, multiple respiratory presentations may be seen. Immunocompetent patients can also present with pulmonary nocardiosis, although this is infrequent. In immunosuppressed patients, Nocardia species can disseminate from the lungs to other body sites, especially the skin and central nervous system (CNS). In some cases, subcutaneous abscesses and cerebral abscesses are responsible for the initial clinical symptoms. CNS involvement should always be excluded in immunosuppressed patients with Nocardia infection, even in those patients without neurologic symptoms. Direct inoculation in the skin may lead to primary cutaneous nocardiosis, usually in immunocompetent patients, with superficial skin involvement, or cutaneous abscesses. Ocular, endovascular, renal, and osteoarticular disease have also been described.
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