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Pulmonary nocardiosis mimicking empyema necessitatis.

Article Excerpt
Nocardia asteroides is a rare cause of pulmonary or disseminated infection in immunocompetent persons. Pleural compromise is common, but empyema necessitatis is very rare. The authors describe an apparently immunocompetent patient with N asteroides infection who had chest wall compromise mimicking empyema necessitatis.

Empyema necessitatis is an empyema that extends through the parietal pleura into the adjacent tissue. (1) The most common cause is tuberculosis, followed by actinomycosis and, less commonly, pulmonary infection with Streptococcus pneumoniae and atypical mycobacteria. (1)

Nocardia asteroides is a slow-growing, Gram-positive, partially acid-fast, ubiquitous organism that is an uncommon pathogen among immunocompetent persons. Risk factors for the development of disease include malignant tumor, transplantation, use of corticosteroids, and autoimmune disease. (2)

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Although pleural compromise is common in pulmonary nocardiosis, chest wall fistulization is uncommon, especially in immunocompetent patients. In older case series, pleural and chest wall involvement were extrapulmonary manifestations in only 8% of patients. 3 Here we describe a patient with pulmonary nocardiosis who presented with a clinical picture mimicking empyema necessitatis.

The case

The patient was a 59-year-old man admitted with an intermittent cough of 4 months' duration. The cough initially was nonproductive but became productive of blood-tinged sputum. It was accompanied by an 8-lb weight loss...