Abstract Introduction Nocardia is a weakly gram-positive, partially acid-fast bacillus. Ubiquitous in the environment, it classically causes opportunistic infections in immunocompromised individuals. We report a case of Pulmonary Nocardiosis in an immunocompetent individual that mimicked lung cancer, and describe the utilization of the Ion shape-sensing robotic-assisted bronchoscope (SSRAB) in clinching the diagnosis. Case Report A 61-year-old male with COPD and a 40-pack-year history of smoking was referred to our center for workup of suspected lung cancer. His symptoms consisted of cough, shortness of breath, and wheezing that began five months prior, following a respiratory illness. Initial chest X-rays were unremarkable. Despite treatment with three courses of antibiotics and steroids, cough persisted. He developed blood-streaked sputum and subsequently lost approximately 10 lbs. A follow-up CT scan of the chest (Figure 1A) revealed a 5.9 x 5.3 x 8.4 cm mass in the left upper lobe (LUL) with partial cavitation and necrosis, along with mediastinal and left hilar adenopathy. A local pulmonologist evaluated him and recommended left upper lobectomy for potential malignancy. At our center, physical exam revealed decreased breath sounds, while PFTs revealed a mild obstructive pattern. We decided on SSRAB for further workup, which revealed extensive mucus plugging throughout the entire tracheobronchial tree. Bronchoalveolar lavage, brushings, and transbronchial needle aspiration revealed marked inflammation with numerous filamentous organisms, but no malignancy. Pulmonary Nocardiosis was confirmed with the microbiologist. He was treated with Trimethoprim-Sulfamethoxazole for six months, with complete clinical and radiological (Figure 1B to 1C) recovery. Discussion Our case highlights a novel utility of the Ion SSARB in clarifying an uncommon presentation of Pulmonary Nocardiosis, thus preventing unnecessary surgical morbidity. Patients with COPD are at greater risk of Pulmonary Nocardiosis, possibly due to airway remodeling in these patients and recurrent corticosteroid use in those with recurrent flares. Importantly, Pulmonary Nocardiosis can mimic lung cancer. Diagnosis can be challenging, with contributory factors including the subacute presentation of Nocardiosis and its relative rarity. Regardless, aggressively chasing a tissue diagnosis is imperative. Navigation bronchoscopy improves diagnostic accuracy, incorporating radial EBUS and a thin flexible scope to reach peripheral lesions. In our patient, SSARB permitted early microbiological confirmation via rapid on-site evaluation. This also minimized procedure-related morbidity, as an unnecessary surgical lobectomy with mediastinal sampling was avoided. With its increasing accessibility, we advocate for the routine use of navigation bronchoscopies as the standard of care in the evaluation of lung nodules or masses. This abstract is funded by: None
Roshy et al. (Fri,) studied this question.