SHM Converge Scientific Abstract ePoster Gallery-A Case of Multiple Lung Cavitation and Chronic Skin Lesion Resembling Mycetoma

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This case describes a 60-year-old man with alcoholic cirrhosis and autoimmune cholangitis who was taking azathioprine and prednisone, placing him at risk for opportunistic infection. He presented with two weeks of shortness of breath, productive cough, and chest pain, along with chronic indurated dark skin lesions on his arms and thighs that initially raised concern for fungal disease or mycetoma. He was hypoxic on exertion, had mild leukocytosis, and an elevated beta-D-glucan. CT chest showed scattered bilateral cavitary nodules and consolidations.<br /><br />Initial workup for bacterial, fungal, mycobacterial, and autoimmune causes was unrevealing. Sputum and BAL cultures showed only oral flora, fungal serologies were negative, tuberculosis PCR was negative, blood cultures were negative, and echocardiography showed no endocarditis. Skin biopsy was nonspecific. He improved clinically and repeat CT after 13 days showed marked reduction in the lung lesions, so he was discharged on amoxicillin-clavulanate. After discharge, AFB culture later grew Nocardia abscessus, confirming nocardiosis. Trimethoprim-sulfamethoxazole was added, but treatment had to be changed because of hyperkalemia and acute kidney injury; he is now being followed closely by Infectious Disease. Brain MRI showed no CNS involvement.<br /><br />The discussion emphasizes that nocardiosis is uncommon but occurs mainly in immunocompromised patients, including those with steroid use, alcoholism, cancer, diabetes, or transplant history. The lungs are the most common site, and skin lesions may mimic other infections such as mycetoma. Diagnosis is often delayed because Nocardia may take weeks to grow and may be missed if antibiotics are started early. The case highlights the importance of considering Nocardia in patients with cavitary lung lesions and skin findings, and of using follow-up imaging to monitor response since antibiotic susceptibility varies by species.

Asset Subtitle

Ashmita Siwakoti

Meta Tag

Author List Ashmita Siwakoti, Hirotaka Kato

Category Clinical Vignettes

Concept Nocardiosis

Concept Immunosuppression

Concept Empiric Antibiotic Therapy

Concept Cavitary Lung Lesion

Concept Risk Factor

Distinguished Non-Finalist

Presenter Organization University of Kentucky

Presenting Author Ashmita Siwakoti

Track Adult

Keywords

nocardiosis

Nocardia abscessus

immunocompromised host

cavitary lung lesions

opportunistic infection

alcoholic cirrhosis

azathioprine

prednisone

skin lesions

trimethoprim-sulfamethoxazole

Nocardiosis

Immunosuppression

Empiric Antibiotic Therapy

Cavitary Lung Lesion

Risk Factor