AbstrAct Introduction: Nocardia and Aspergillus are important causes of opportunistic infections in immunocompromised individuals. An aggressive workup is essential since these infections are remediable but potentially mortal. case report: We describe a case of a 50-year-old diabetic female with pulmonary aspergillosis who presented with cough and breathlessness for one and ahalf months. she was given steroids and itraconazole for the same but there was no relief. Later on, bronchoalveolar lavage on Kinyoun stain showed Nocardia. conclusion: this case highlights the importance to look for other causes as well in patients with pulmonary aspergillosis not responding to treatment since delay in diagnosis can be fatal for the patient

Agarwal Pk

Al Garg

Ambuj Garg

Gunjan Garg

Pratyush Miglani

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Edorium Journal of Medicine, Vol. 1; 2014.
Edorium J Med 2014;1:1–3.  
www.edoriumjournalofmedicine.com
Garg et al. 1
Case report opeN aCCess 
Co-existence of nocardiosis with pulmonary aspergillosis 
in a single patient
Gunjan Garg, Pratyush Miglani, Ambuj Garg, Agarwal PK
AbstrAct
Introduction: Nocardia and Aspergillus are 
important causes of opportunistic infections in 
immunocompromised individuals. An aggressive 
workup is essential since these infections are 
remediable but potentially mortal. case report: 
We describe a case of a 50-year-old diabetic 
female with pulmonary aspergillosis who 
presented with cough and breathlessness for 
one and ahalf months. she was given steroids 
and itraconazole for the same but there was 
no relief. Later on, bronchoalveolar lavage on 
Kinyoun stain showed Nocardia. conclusion: 
this case highlights the importance to look for 
other causes as well in patients with pulmonary 
aspergillosis not responding to treatment since 
delay in diagnosis can be fatal for the patient.
Keywords: Aspergillus, Nocardia, Diabetes 
mellitus, tuberculosis
Gunjan Garg1, Pratyush Miglani2, Ambuj Garg3, Agarwal 
PK4
Affiliations: 1MBBS, Post Graduate Student (Internal 
Medicine), Department of Internal Medicine, Sir Ganga 
Ram Hospital, New Delhi, Delhi, India; 2MBBS, MD, Senior 
Resident, Department of Internal Medicine, Sir Ganga Ram 
Hospital, New Delhi, Delhi, India; 3MBBS, DNB, Associate 
Consultant, Department of Internal Medicine, Sir Ganga 
Ram Hospital, New Delhi, Delhi, India; 4MBBS, MD, Sen-
ior consultant, Department of Internal Medicine, Sir Ganga 
Ram Hospital, New Delhi, Delhi, India.
Corresponding Author: Dr. Gunjan Garg, Room No. 1407, 
4th Floor, Department of Medicine, Sir Ganga Ram Hospital, 
Old Rajinder Nagar, New Delhi, Delhi-110060, India; Mob: 
+918130806986; Email: gunjangarg88@yahoo.co.in
Received: 12 June 2014
Accepted: 01 July 2014
Published: 07 October 2014
How to cite this article
Garg G, Miglani P, Garg A, Agarwal PK. Co-existence 
of nocardiosis with pulmonary aspergillosis in a 
single patient. Edorium J Med 2014;1:1–3.
Article ID: 100001M05GG2014
*********
doi:10.5348/M05-2014-1-CR-1
IntroDuctIon
Pulmonary disease is the common manifestation of 
infection by Nocardia and Aspergillus and is usually 
fatal if it goes unrecognized. They are unusual in 
immunocompetent individuals and co-infection with 
both is even odder. We report one such case of mixed 
infection with Nocardia and Aspergillus in a diabetic 
female.
cAsE rEPort
A 50-year-old diabetic female, suffering from post-
tubercular bronchiectasis presented with worsening 
cough and breathlessness over past one and ahalf 
months. For these ongoing symptoms, she was 
evaluated elsewhere and diagnosed as pulmonary 
aspergillosis (serum Immunoglobulin E levels were >2500 
IU/mL, absolute eosinophil counts were 1600/mm3, 
immunoglobulin G anti-Aspergillus titre was >200). 
She was taking oral glucocorticoids and itraconazole 
for the same. On hospitalization, she complained of 
persistent cough with expectoration and breathlessness. 
Respiratory system examination revealed crepitations in 
bilateral lung fields. All the laboratory investigations were 
Edorium Journal of Medicine, Vol. 1; 2014.
Edorium J Med 2014;1:1–3.  
www.edoriumjournalofmedicine.com
Garg et al. 2
normal except for glycated hemoglobin which was 8.9%. 
Microbiological examination of sputum was normal. 
Chest radiograph (Figure 1) revealed homogeneous 
opacities in left mid zone and right upper zone. At this 
stage, she was managed with intravenous antibiotics, oral 
glucocorticoids and other supportive measures. Follow-
up chest X-rays showed increase in the size of left-sided 
opacity. Contrast-enhanced computed tomography scan 
of thorax revealed bronchiectasis in bilateral lungs with 
necrotic consolidation in left upper lobe with infective 
bronchiectatic segments in right upper lobe and necrotic 
tree in bud appearance in bilateral lungs. Citing no relief 
to the patient, bronchoscopy was carried out which was 
normal. Bronchoalveolar lavage analysis was negative 
for Gram’s, acid-fast bacilli and fungal stain but Kinyoun 
stain showed growth of Nocardia.  The patient was 
additionally started on oral co-trimoxazole DS twice daily 
according to sensitivity of organism cultured. By fourth 
day, she was symptomatically better and her chest X-ray 
showed resolution of the lesion (Figure 2). Subsequently, 
the patient was discharged in stable condition with advice 
for further follow-up.
DIscussIon
Pulmonary aspergillosis is an allergic or hypersensitive 
reaction to fungus. It is commonly caused by Aspergillus 
fumigatus. The incidence of aspergillosis has increased 
with rise in prevalence of immunocompromised patients 
associated with the management of malignancy, organ 
transplantation, autoimmune and inflammatory 
conditions; critically ill patients and those with chronic 
obstructive pulmonary disease. It is characterized by 
cough, breathlessness, coughing up thick sputum casts 
and recurrent transient chest radiographic infiltrates. 
The diagnostic features include markedly increased 
total IgE (>1000 IU/mL), positive skin prick test to 
Aspergillus fumigatus extract or detection of specific 
IgE and IgG levels [1]. Radiologic features consists of 
nodules ranging from 1–3 cm which cavitate in 50% of 
patients [2]. The diagnosis is based upon the presence 
of a combination of clinical, biological and radiological 
criteria [3]. Introduction of new non-invasive tests, with 
more effective and better-tolerated drugs, has resulted in 
lower mortality rates. 
Pulmonary nocardiosis is the most common clinical 
presentation of Nocardia because inhalation is the 
primary route of bacterial exposure. Majority of patients 
with pulmonary nocardiosis have identifiable risk factors 
mainly corticosteroid or other immunosuppressant 
therapy [4]. It presents with productive or non-productive 
cough, pleuritic pain, hemoptysis, fever, anorexia, 
malaise, and weight loss. The chest X-ray findings can 
be variable, displaying focal or multifocal disease with 
nodular and/or consolidation infiltrate as well as cavitary 
lesions [5]. The cavitary lesions in immunodeficient 
individuals are caused by various organisms besides 
Nocardia like Staphylococcus aureus, Pseudomonas, 
Mycobacterium tuberculosis. The cavitary lesion can 
even masquerade malignancy [6]. Treatment mainly 
constitutes 10–20 mg/kg of trimethoprim and 50–100 
mg/kg of sulfamethoxazole per day, gradually they can be 
tapered in view of positive clinical response from patient. 
Sulfonamide resistant Nocardia species can be treated 
with third generation cephalosporins and imipenem [7].
Figure 2: Chest X-ray showing homogeneous opacity in left mid 
zone but less demarcated than previous X-ray.
Figure 1: Chest X-ray showing homogeneous opacity in left mid 
zone and right upper zone.
Edorium Journal of Medicine, Vol. 1; 2014.
Edorium J Med 2014;1:1–3.  
www.edoriumjournalofmedicine.com
Garg et al. 3
concLusIon
The co-existence of aspergillosis and nocardiosis in 
the same patient is rarely reported in literature. Hence, 
we emphasize our readers to keep their differential 
diagnosis wide open while dealing with such cases. 
*********
Author contributions
Gunjan Garg – Substantial contributions to conception 
and design, Acquisition of data, Analysis and 
interpretation of data, Drafting the article, Revising 
it critically for important intellectual content, Final 
approval of the version to be published
Pratyush Miglani – Analysis and interpretation of data, 
Revising it critically for important intellectual content, 
Final approval of the version to be published
Ambuj Garg – Analysis and interpretation of data, 
Revising it critically for important intellectual content, 
Final approval of the version to be published
Agarwal PK – Analysis and interpretation of data, 
Revising it critically for important intellectual content, 
Final approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
conflict of Interest
Authors declare no conflict of interest.
copyright
© 2014 Gunjan Garg et al. This article is distributed 
under the terms of Creative Commons Attribution 
License which permits unrestricted use, distribution 
and reproduction in any medium provided the original 
author(s) and original publisher are properly credited. 
Please see the copyright policy on the journal website for 
more information.
rEFErEncEs
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2. Mohan A, Sharma SK, Arora VK, Sharma S, 
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Nocardiosis in an old tubercular cavity masquerading 
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3. Gupta RK, Chandr A, Gautam PB. Allergic 
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4. Minero MV, Marín M, Cercenado E, Rabadán PM, 
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century. Medicine (Baltimore) 2009 Jul;88(4):250–
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5. Beaman BL, Beaman L. Nocardia species: Host-
parasite relationships. Clin Microbiol Rev 1994 
Apr;7(2):213–64.
6. Sharma B, Ghosh G, Kamble U, et al. Allergic Broncho 
Pulmonary Aspergillosis Complicated by Nocardiosis. 
Case Rep Pulmonol 2012;2012:758630.
7. Mootsikapun P, Intarapoka B, Liawnoraset W. 
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Co-existence of nocardiosis with pulmonary aspergillosis in a single patient

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Co-existence of nocardiosis with pulmonary aspergillosis in a single patient

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