Pulmonary infection by Nocardia saintgeorgesii mimicking lung cancer with concurrent pulmonary embolism in an immunocompetent host: a case highlighting the diagnostic role of mNGS

TL;DR

A case of Nocardia infection mistaken for lung cancer was correctly diagnosed using mNGS, revealing a possible link to pulmonary embolism.

Contribution

Highlights the diagnostic utility of mNGS in Nocardia cases and suggests a potential underrecognized association with thrombotic events.

Findings

mNGS provided a definitive diagnosis of Nocardia infection when imaging suggested lung cancer.

The patient also had a concurrent pulmonary embolism, suggesting a possible link to Nocardia infection.

Treatment with ceftriaxone and sulfamethoxazole led to significant clinical improvement.

Abstract

Pulmonary nocardiosis presents a diagnostic challenge due to its frequent mimicry of lung cancer on imaging and the low sensitivity of conventional cultures. We report a case initially misdiagnosed as malignancy in an immunocompetent host, where metagenomic next-generation sequencing (mNGS) provided a definitive diagnosis and revealed a concurrent pulmonary embolism, suggesting a potential underrecognized association.

This report describes a case of PN in an immunocompetent patient who was initially misdiagnosed with lung cancer based on imaging findings but later confirmed as pulmonary nocardiosis via mNGS. Notably, the patient also developed pulmonary embolism (PE). Empirical antibiotic therapy with piperacillin-tazobactam was initiated initially, supplemented with inhaled ipratropium bromide and expectorants to alleviate symptoms. Based on imaging findings suggestive of lung cancer, an invasive procedure was scheduled. mNGS was subsequently performed for further diagnosis. The subsequent results, along with CT scans, indicated no evidence of malignancy, leading to a consideration of Nocardia infection. The treatment regimen was then adjusted to ceftriaxone sodium combined with compound sulfamethoxazole, and the surgical schedule was canceled. The patient’s condition showed significant improvement, and he was discharged without fever or dyspnea. Some literature suggests that many PN patients present with concurrent deep vein thrombosis (DVT), suggesting a potential yet underrecognized association between Nocardia infection and thrombotic events. However, this correlation has not been fully reported before.

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