A 62-year-old female patient presented to the emergency department with chief complaints of breathlessness for 10 years, cough with expectoration, and lower limb swelling since last 4 days. The breathlessness was associated with history of orthopnea, paroxysmal nocturnal dyspnoea (PND), and palpitations. There was a gradual increase in difficulty in breathing over the past 4 days with progression from grade 2 to grade 3. The cough was gradual in onset and was associated with yellowish expectoration and no haemoptysis. The pain in the lower limbs was seen along with abdominal swelling and facial puffiness. The patient was a known case of type 2 DM but was on irregular mediation. There was no history of HTN, PTB, or any other comorbidities. On examination, she was febrile; heart rate was 116 beats/min; respiratory rate was 27 breaths/min; blood pressure was 130/90  mm Hg; and oxygen saturation was 915 while breathing room air. The patient had pallor and bilateral pedal oedema. Systemic examination including respiratory system did not reveal any significant findings. The total leukocyte count was 8520/mm3 with 90% neutrophils and 3% lymphocytes. The haemoglobin was 9.6 g/dl, and the erythrocyte sedimentation rate was 102/hr. Serum urea was 75  mg, and creatinine was 2.5  mg/dl. An empirical antibiotic, modified dose of piperacillin and tazobactam was started along with other supportive treatment.
Sputum sample was sent to microbiology laboratory for KOH examination which incidentally revealed weak, acid-fast, and filamentous bacilli resembling Nocardia spp. She was immediately initiated on modified dose of trimethoprim/sulfomethaxozole and linezolid. As the patient showed gradual improvement in his condition, he was discharged on the same drugs. He successfully completed 3 months of antibiotics with satisfactory clinico-radiological improvement.