Diagnosing Disseminated Nocardiosis in a Patient With COVID-19 Pneumonia

Abstract

Signs and symptoms of atypical pneumonia include fever, shortness of breath, cough, and chest pain. During the coronavirus disease 2019 (COVID-19) pandemic, identifying other causes of febrile respiratory illness in patients who tested positive for COVID-19 has been very challenging. Concerns over infecting healthcare personnel and other patients can impede further evaluations like bronchial lavage, lung biopsies, and other invasive tests. A very high index of suspicion, perhaps unreasonably so, is required to perform invasive tests to investigate alternative possible causes of the illness. We present the case of a 63-yearold man who presented to the hospital with dyspnea. Chest X-ray demonstrated a consolidation in the left lower lobe lung field with a possible underlying mass, and the patient tested positive for COVID-19. He received the standard treatment for COVID pneumonia at the time in our institution (remdesivir and dexamethasone), empiric antibiotics for community-acquired pneumonia, and was eventually discharged home with supplemental oxygen. Several days later, the patient returned to the hospital again with worsening dyspnea and was readmitted. Persistent illness and worsening imaging prompted bronchoscopy. The bronchoscopy showed narrowing of the airway in the left upper lobe, and Nocardia asteroides was isolated from bronchial aspirate. The isolation of Nocardia prompted an investigation for central nervous system involvement with an magnetic resonance imaging (MRI) of the head. The MRI demonstrated multiple bilateral ring-enhancing lesions in the brain. To our knowledge, this is the first reported case of disseminated nocardiosis superimposed on COVID-19 pneumonia.

Case report: Nocardial brain abscess in a persistently SARS-CoV-2 PCR positive patient with systemic lupus erythematosus

“…Systemic nocardiosis superimposed on COVID-19 has been previously described in a diabetic patient ( 19 ). To our knowledge, this is the first reported case of primary cerebral nocardiosis in a patient with persistent SARS-CoV-2 infection and SLE.…”

Pulmonary Nocardiosis as an Opportunistic Infection in COVID-19

“…Only four other reports of nocardiosis associated with COVID-19 have been reported to date. The first case occurred in a 63-year-old man who presented with dyspnea several days after severe COVID-19 treated using dexamethasone and remdesivir [ 2 ] . In this case, pulmonary and neurological nocardiosis was diagnosed but due to preexisting lesions, the nocardiosis was thought to be present prior to the SARS-CoV-2 infection.…”

“…Occurrence of secondary bacterial pneumonia infections in COVID-19 has been estimated to be around 16% with gram-negative bacteria ( Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Stenotrophomonas maltophilia among others) or with gram-positive bacteria (mainly Staphylococcus aureus ), less frequently (6%) with fungi ( Aspergillus spp or Fusarium spp), and rarely with other opportunistic pathogens such as Pneumocystis jirovecii [ 1 ] . Despite extensive use of steroids and other immunosuppressive drugs in COVID-19 treatment, four cases of nocardiosis during COVID-19 have been reported [ 2 – 5 ] , of which two cases were suspected to be present before COVID-19 infection. We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia in an 83-year-old male suffering from COVID-19.…”

Pulmonary nocardiosis after covid-19 infection: case report and literature review

“…An English literature review showed only other five reports of these associations. Data regarding these cases are shown [6][7][8][9][10].…”