Case Presentation: We describe a 56-year-old farmworker man with a history of renal transplant 5 months prior, T2DM, and HTN, with coinfection of 3 Nocardia species and Aspergillus niger. The patient presented with 3 weeks of unresolving cough, right sided pleuritic chest pain, night sweats, and fatigue despite treatment for community acquired pneumonia (with ceftriaxone and cefdinir) while visiting family in Idaho. Further workup from OSH ED was significant for a CT chest with contrast that showed lung opacities, and PCP follow up for potential malignancy was recommended. Due to persistent symptoms, the patient was admitted for lung opacity evaluation, including malignancy and infection workup. On day 7, patient developed fever and was started on vancomycin, cefepime and fluconazole. On day 13, he underwent bronchoscopy with BAL which was positive for Aspergillus niger and Nocardia species (abscessus complex, exalbia, gamkensis). Medications were switched to high dose sulfamethoxazole/trimethoprim, imipenem/cilastatin, and posaconazole while undergoing further workup for disseminated nocardiosis and aspergillosis. On day 17, the patient developed a hand nodule and biopsy revealed Aspergillus consistent with disseminated aspergillosis. At the end of hospital stay, patient was diagnosed with pulmonary nocardiosis and disseminated aspergillosis (lung and skin) and was discharged with trimethoprim/sulfamethoxazole, doxycycline and posaconazole. The patient followed up closely with infectious disease clinic and completed 3.5 months of sulfamethoxazole/trimethoprim (discontinued due to hyperkalemia), 12 months of doxycycline, and continued posaconazole indefinitely due to immunocompromised status.
Discussion: Both Nocardia and Aspergillus are found in soil and water and are rare opportunistic infections that affect mostly immunocompromised patients or people with occupational exposure like farmers or gardeners. Nocardia is a gram positive, branching bacillus that frequently colonizes the lungs in immunosuppressed individuals but can potentially seed any organ system. Aspergillus niger is a rare cause of pneumonia compared to Aspergillus fumigatus that tends to be more potent in warm weather. The few cases reported of Aspergillus species soft tissue infections have shown increased mortality due to necrotizing fasciitis. The confection of these two species is rarer and presents challenging diagnostic and treatment decisions for clinicians. Unfortunately, this patient had increased exposure and multiple risk factors for developing these two infections. He was diabetic, had recent renal transplant requiring high doses of anti-thymocyte globulin followed by steroid taper, and was a farmworker in the San Joaquin Valley in California.
Conclusions: This patient could have benefited from early admission and workup of lung opacities. Sooner identification and treatment could have potentially prevented the patient from developing disseminated aspergillosis. This case highlights the importance of considering rare and opportunistic infections especially in the immunocompromised population early to prevent delays in care, which can lead to increased severity of the disease, longer hospitalization, and possibly a worse prognosis.