A 60-year-old male with hepatitis C infection status-post treatment with a negative viral load and chronic kidney disease (CKD) due to biopsy-confirmed focal segmental glomerulosclerosis (FSGS) presented with pleuritic chest pain, dyspnea, fever, and cough for a few days. He denied hemoptysis, sweats, weight loss, travel, or sick contacts. Of note, he had been prescribed high-dose steroids one month prior to presentation for FSGS and had not been prescribed any prophylactic antibiotics.
Examination was notable for tachypnea to 24 breaths per minute, hypoxia to 92% on room air, and crackles auscultated in the left lung base. Laboratories were notable for leukocytosis to 27,000 cells/uL, acute kidney injury on his baseline CKD, and a negative human immunodeficiency virus (HIV) screen. Chest x-ray showed a left lower lobe infiltrate.
He was treated empirically for community-acquired pneumonia with levofloxacin. PJP prophylaxis was also started given his steroid use; atovaquone was selected as trimethoprim-sulfamethoxazole could not be used given his CKD. He became febrile on this regimen, so coverage was broadened to vancomycin and cefepime until sputum cultures grew Gram-positive branching rods suggestive of Nocardia. Antibiotics were narrowed to linezolid and atovaquone prophylaxis. Brain magnetic resonance imaging was performed and did not show an abscess. Interestingly, PJP sputum stains also returned positive a few days later, so atovaquone dosing was increased to complete treatment. On a subsequent clinic visit, the patient had completed PJP treatment and was continuing pulmonary nocardiosis treatment for a total of six months. His cough, dyspnea, and hypoxia had resolved.
Discussion: Nocardiosis is an uncommonly diagnosed infection, with less than 1,000 new cases in the United States every year per the Centers for Disease Control. Significant risk factors are corticosteroid use, HIV infection, and malignancy. Pulmonary involvement can be seen in approximately two-thirds of cases. Even more uncommonly seen is concomitant pulmonary nocardiosis and PJP. There are case reports detailing such instances, however all described patients were either receiving chemotherapy, post-transplant on multiple systemic immunosuppressive agents, or HIV positive. Our patient presented unusually, as he had only been taking high-dose steroids for one month.
Conclusions: This case demonstrates the diagnostic challenges encountered when treating acutely-ill immunocompromised patients and the need to maintain a broad differential. It also demonstrates the utmost importance to consider PJP prophylaxis for any patient on high-dose steroids.