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A 61-year-old woman was transferred with a complaint of a fever and productive cough. She had tested positive for Mycobacterium avium and Nocardia cyriacigeorgica at least twice, and Streptococcus pneumonia (PISP) was isolated (3+) from her purulent sputum. As radiological findings, a lower lung field-dominant infiltration shadow and nodular shadow with cavity were recognized in the bilateral lung fields. We diagnosed her with pneumococcal pneumonia co-infection with M. avium and N. cyriacigeorgica. She was treated with MEPM for pneumococcal pneumonia, a standard regimen containing clarithromycin for pulmonary M. avium complex (MAC) disease, and sulfamethoxazole/trimethoprim for pulmonary nocardiosis. She improved with appropriate treatment.

We report a case of Nocardia exalbida (N.exalbida)-induced pneumonia in a 70-year old Japanese man with lung cancer and radiation pneumonitis. He initially received doripenem (1.5 g/day) for pneumonia treatment, and N.exalbida was identified by a clone library analysis of bronchoalveolar lavage fluid obtained from the pneumonia lesion. The doripenem dosage was therefore increased to 3.0 g/day with adjunctive trimethoprim/sulfamethoxazole, and his pneumonia improved. N. exalbida is susceptible to antibiotics; thus, in nocardiosis, N. exalbida infection might be associated with a good response to treatment, although its clinical findings are non-specific and similar to those of other Nocardia infections.

Pulmonary reinfection by Nocardia has been rarely reported. We describe a case of pulmonary reinfection by Nocardia in an immunocompetent patient. An 82-year-old immunocompetent woman with bronchiectasis presented with exacerbation of cough. She had a history of pulmonary nocardiosis three years earlier. At that time, Nocardia species were cultured from the sputum and identified as N. cyriacigeorgica with 16S ribosomal RNA gene sequencing. In the present episode, cultures of sputum and bronchial washing specimens grew N. beijingensis, which was identified with 16S ribosomal RNA gene sequencing. Pulmonary reinfection by different Nocardia species can occur in immunocompetent patients.

A 73-year-old man was admitted to our hospital with disturbance of consciousness, fever and headache. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with neutrophil predominance, increased protein and low glucose. CSF and blood cultures yielded negative results. Antibiotics and antituberculous drugs were started for meningitis. An antimycotic was also added. The patient died from transtentorial hernia 99 days after admission. Autopsy revealed meningitis, ventriculitis and brain abscess, and Nocardia araoensis was detected in pus from the left lateral ventricle. This appears to represent the first report of N. araoensis meningitis complicated by ventriculitis and brain abscess.

Objective Pulmonary nocardiosis frequently develops as an opportunistic infection in patients with malignant tumor and is treated with steroids. This study was performed to clarify the clinical features of pulmonary nocardiosis in Japan. Methods The patients definitively diagnosed with pulmonary nocardiosis at our hospital between January 1995 and December 2015 were retrospectively investigated. Results Nineteen men and 11 women (30 in total) were diagnosed with pulmonary nocardiosis. Almost all patients were complicated by a non-pulmonary underlying disease, such as malignant tumor or collagen vascular disease, or pulmonary disease, such as chronic obstructive pulmonary disease or interstitial pneumonia, and 13 patients (43.3%) were treated with steroids or immunosuppressors. Gram staining was performed in 29 patients, and a characteristic Gram-positive rod was detected in 28 patients (96.6%). Thirty-one strains of Nocardia were isolated and identified. Seven strains of Nocardia farcinica were isolated as the most frequent species, followed by Nocardia nova isolated from 6 patients. Seventeen patients died, giving a crude morality rate of 56.7% and a 1-year survival rate of 55.4%. The 1-year survival rates in the groups with and without immunosuppressant agents were 41.7% and 59.7%, respectively, showing that the outcome of those receiving immunosuppressants tended to be poorer than those not receiving them. Conclusion Pulmonary nocardiosis developed as an opportunistic infection in most cases. The outcome was relatively poor, with a 1-year survival rate of 55.4%, and it was particularly poor in patients treated with immunosuppressant agents. Pulmonary nocardiosis should always be considered in patients presenting with an opportunistic respiratory infection, and an early diagnosis requires sample collection and Gram staining.

Nocardiosis is an uncommon infection that occurs primarily in immunocompromised patients. We herein report an extremely rare case of Nocardia farcinica (N. farcinica) pericarditis. A 53-year-old man with nephrotic syndrome that required chronic corticosteroid therapy presented with pleuritic chest pain and cardiac tamponade. Pericardiocentesis revealed purulent pericardial effusion and a bacteriological examination showed the characteristic branching filamentous bacteria identified as N. farcinica. Aggressive surgical drainage and a trimethoprim-sulfamethoxazole based regimen resulted in clinical improvement. To the best of our knowledge, this is the first reported case of N. farcinica pericarditis in Thailand.

A 66-year-old man who suffered from an acute exacerbation of interstitial pneumonia developed a cavitary lesion after taking immunosuppressive drugs. He was diagnosed with cytomegalovirus (CMV) pneumonia. CMV was not thought to be the underlying cause of the cavitary lung lesions, as only six cases have been described thus far. However, this case clearly demonstrates that the development of cavitary lung lesions can be caused by CMV. Following CMV pneumonia, cavitary lesions again occurred in the patient's lungs that were thought to be the first case of cavitary lesions caused by Nocardia asiatica infection.

We report a 45-year-old man with HIV/AIDS who developed mediastinal lymphadenopathy caused by Nocardia asteroides infection that was diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). He was an untreated HIV-infected man who was admitted to our hospital because of Pneumocystis pneumonia and Cytomegalovirus pneumonia. After treatment for pneumonia, cough and fever recurred and chest computed tomography revealed subcarinal lymphadenopathy with rim enhancement. To identify the etiology, we performed EBUS-TBNA and obtained purulent exudates which contained N. asteroides. EBUS-TBNA is a useful and safe technique for the diagnosis of mediastinal infectious lymphadenopathy of unknown origin.

We report the case of a 50-year-old man admitted for cardiac tamponade. He was diagnosed with acute pneumonia. He had no previous medical history, but exhibited a body mass index of 41. Two days before admission, he complained of chest pain irradiating to the neck lateral side. Massive cardiac tamponade developed over 48 hours. There was no obvious cause for immunodepression. Pericardial puncture was ineffective, due to obesity and fluid high viscosity. Surgery was undertaken (Marfan intervention). Pericardial fluid was found to be purulent; direct examination revealed nocardia as bacteria with typical filamentous, branching rods. Despite adapted antibiotic treatment the patient died within a few hours. Acute pericarditis due to Nocardia is discussed.

A 40-year-old woman undergoing prednisolone and cyclosporine therapy for subcutaneous panniculitic T-cell lymphoma complained of a cough for a few weeks. A chest X-ray revealed bilateral diffuse granular shadows. Additionally, the patient was discovered to have multiple subcutaneous abscesses. Gram-stained smears of sputum and pus from the abscess showing branched gram-positive rods led to a diagnosis of pulmonary nocardiosis with dissemination to the lungs and subcutaneous tissues. Combination therapy consisting of sulfamethoxazole/trimethoprim and panipenem/betamipron produced rapid improvement of radiographic abnormalities. It is suggested that pulmonary nocardiosis should be considered in the differential diagnosis of diffuse granular shadows on chest X-rays, especially in immunocompromised patients.