A 37-year-old middle-age gentleman, who was otherwise fit and well, presented with persistent high-grade fever for more than ten days duration associated with intermittent productive cough of whitish sputum. He also had arthralgia and myalgia. He denied any hemoptysis, night sweats, shortness of breath, or pleuritic chest pain. He did not have any constitutional symptoms such as loss of weight or appetite. He was previously diagnosed with smear-positive pulmonary tuberculosis (PTB) where he completed a total duration of 9 months of anti-TB therapy. During this course of therapy, he had recurrent admissions for empyema thoracic, where a chest tube drainage and prolonged antibiotic therapy were needed. He was a nonsmoker and was doing a rural job, in the form of farming for a living. He denied alcohol consumption and the usage of recreational drugs.
On examination, he appeared tachypneic with a respiratory rate of 24 breaths/minute. His other vital signs were normal. There were reduced air entry and vocal resonance with the presence of stony dullness on examination on the lower zone of the right lung. There was a skin lesion over the face and scalp which resembles seborrhoeic dermatitis. Other systemic examinations were unremarkable.
In terms of blood investigations, he had leucocytosis (WCC of 14.9 x 109/L) and thrombocytosis (platelet count of 609 x 109/L), with significantly raised inflammatory markers (ESR of 102 and CRP of 137.4). A sputum acid-fast bacillus was scanty 1+, and the sputum mycobacterium culture was negative. Hepatitis and HIV screenings were negative. Chest radiography showed consolidative changes with mild to moderate pleural effusion on the right side (Figure 1). The pleural analysis shows the exudative picture with protein ratio (pleural protein) : (serum protein) = (3.3 g/L : 77 g/L) and lactate dehydrogenase (LDH) ratio (pleural LDH) : (serum LDH) = (3317 U/L : 315 U/L). Cytology was sent and no malignancy detected, and an acid-fast bacillus was also negative. Skin biopsy was taken and showed Paecilomyces species. CT thorax was performed and revealed a multiloculated collection within the right hemithorax depicting a thickened enhancing wall which joins at the margins of the collection to form the split pleura sign. This is associated with the compression atelectasis surrounding it (Figure 2).
The patient was referred to a cardiothoracic surgeon, and right thoracotomy and decortications were done in February 2016. The findings from the operation are thickened cortex measuring 0.8 cm plastered to the surface of the right lung with small pus collection. Tissue culture and sensitivity were sent and reported as Gram-positive and thin branching filaments. Modified Ziehl-Neelsen staining reported as many branching of acid-fast bacilli which is consistent with the morphology of Nocardia species. And it is sensitive to sulfamethoxazole-trimethoprim (Bactrim). He was started on IV imipenem 500 mg QID and oral Bactrim 4/4/3 tablets TDS total for 4 months. After completed treatment, the patient was getting better and no more shortness of breath and cough. Repeated CT thorax noted no more pleural effusion or empyema (Figure 3).