A case of Disseminated Nocardia beijingensis in an Immunocompetent Patient, Manifesting as Subcutaneous and CNS Nocardiosis.

Introduction Nocardiosis is an uncommon infection, typically encountered in immunocompromised patients. With only 5 cases reported thus far in the United States, we present a case of disseminated Nocardia beijingensis in an immunocompetent patient, involving the lung, subcutaneous tissue, and CNS. Clinical Findings A 60-year-old immunocompetent male with no significant medical history presents to our institution after a complicated medical course, beginning with vague respiratory complaints. Initial work-up revealed a large right upper lung mass of unclear etiology. A month later he had a syncopal episode followed by the development of focal neurologic deficits. Main Diagnoses, Therapeutics Interventions, and Outcomes Sputum cultures obtained after the patient’s syncopal episode grew gram positive rods. CT of the chest at this time made note of a new 17 mm subcutaneous mass, which was biopsied, revealing gram positive rods with partial acid-fast staining. MRI of his brain weeks later showed multiple enhancing lesions with vasogenic edema scattered throughout. Tissue culture from his chest mass was sent off to the Mayo Clinic and ultimately grew out Nocardia beijingensis. The patient was ultimately started on the appropriate antibiotics therapy and has made significant clinical improvement. Conclusions Though Nocardia is often associated with an immunocompromised state, it is an important entity to consider in patients with pulmonary findings as well as evidence of disseminated disease, particularly CNS manifestations, regardless of immune status. A high index of suspicion is needed, as definitive diagnosis often takes weeks due to slow-growing nature of Nocardia species.