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Weekly Chest CasesArchive of Old Cases

Case No : 1323 Date 2023-02-28

  • Courtesy of Jung In Jo, Jooae Choe, Kyung-Hyun Do / Asan medical center
  • Age/Sex 74 / F
  • Chief ComplaintDyspnea (onset: 2days ago) History: liver transplantation for liver cirrhosis (3years ago)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Pulmonary nocardiosis
Radiologic Findings
Fig 1. Chest PA shows two subpleural cavitary mass-like opacities in both mid-lung zones. Multiple nodular and consolidative opacities along the pleural surface and lung parenchyma are seen in the right hemithorax.
Fig 2-4. CT scans reveal two irregular thick-walled cavitary masses in both upper lobes. Multiple well-defined pleuroparenchymal nodules are also noted in both hemithoraces, especially the right hemithorax.
Fig 5. Gadolinium-enhanced T1-weighted MR image of the brain shows a small low signal intensity lesion with enhancing rim in left parietal lobe, suggesting a microabscess.
On sputum culture, Nocardia nova was identified.
Brief Review
Nocardia is a gram-positive, aerobic bacteria found in soils worldwide. It is responsible for acute or chronic infections primarily in immunocompromised hosts, particularly those with impaired cell-mediated immunity related to AIDS and transplant.
On chest CT images, multifocal lung consolidation with internal decreased attenuation, and possible cavitation is the predominant finding. A solitary or, more often, multiple lung nodules of various sizes have also been reported. Cavitation is common, being seen in one-third or more of patients, and may occur within areas of consolidation, nodules, or masses. The pleura or chest wall may be involved in patients, usually from direct extension, causing empyema necessitates. Mediastinal and hilar lymphadenopathy is not a usual feature of pulmonary nocardiosis. Immunocompromised patients tend to present with disseminated disease. Disseminated nocardiosis occurs through hematogenous spread from the lungs most commonly to the CNS, skin, and joints. Differential diagnosis for pulmonary nocardiosis includes other causes of lung consolidation, cavitation, and nodules such as other infections, vasculitis, and malignancy.
Treatment of pulmonary nocardiosis usually includes high-dose sulfonamide therapy. Surgical drainage is not typically required for pulmonary disease.
References
1. Kanne JP, Yandow DR, Mohammed TL et-al. CT findings of pulmonary nocardiosis. AJR Am J Roentgenol. 2011;197 (2): W266-72.
Keywords

No. of Applicants : 95

▶ Correct Answer : 33/95,  34.7%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - , Japan SUZUNE TSUKAMOTO
  • - Jichi Medical University Hospital , Japan JUN KANZAWA
  • - , Japan KYOKO NAGAI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - Seoul National University Hospital , Korea (South) HYUNGIN PARK
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Osaka University , Japan AKINORI HATA
  • - Kaneda hospital , Japan HIROFUMI MIFUNE
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - , Korea (South) MINJI KIM
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Yamanashi Prefectural Central Hospital , Japan HIROAKI WATANABE
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Ajou University Hospital , Korea (South) YOU NA KIM
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Other , Korea (South) SEONG WON JANG
  • - Manipal hospital Hebbal, Bengaluru , India PRAVIN KUMAR M
  • - Hyogo Prefectural Kobe Children , Japan SHUHEI NORIMOTO
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - Matsunami General Hospital , Japan TARO TAKEDA
  • - , Japan YUMI MAEHARA
  • - Shiga University of Medical Science , Japan RYO UEMURA
  • - , Japan YUKI HAYASHI
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
  • - Kyoto university , Japan AKIHIKO SAKATA
▶ Correct Answer as Differential Diagnosis : 13/95,  13.7%
  • - Wakayama Red Cross Hospital , Japan TOMOAKI OTANI
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Other , Korea (South) SEONGSU KANG
  • - , Japan FUMINORI MIYOSHI
  • - , United Arab Emirates GAYATHRI GANAPATHY
  • - , Japan KENTARO KOTANI
  • - Shiga General Hospital , Japan YUSAKU MORIBATA
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Others , India PURUSHOTHAMA RAO TUMMALA
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - Kyoto University , Japan SHO KOYASU
  • - Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
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