A 46-yr-old female patient presented to us with a history of low-grade fever, cough with expectoration, and increasing breathlessness for last 2 months. There was no history of weight loss, chest pain or pedal edema. There is a history of pulmonary tuberculosis 20 years back. She was taking bronchodilators for COPD with no exacerbation in the last 6 months. She denied taking systemic corticosteroids for her respiratory symptoms. She also denied any history of diabetes, hypertension, alcohol or other drug abuse. On physical examination, she was febrile, with a pulse rate of 100/min, blood pressure of 100/68 mm hg, oxygen saturation of 92% on room air, and respiratory rate of 22/min with use of respiratory accessory muscles. Respiratory examination revealed bibasilar inspiratory crackles and bronchial breath sound on the left infra-axillary region. On haematological investigations, complete blood counts revealed leukocytosis (22470/mm3). Other biochemical investigations were within normal limit except increased CRP (182.4, normal <1 ng/ml). Her viral markers (HIV, HbsAg, Anti HCV) were negative. The chest radiograph showed (Fig. 1, A) multifocal patchy consolidation in bilateral lower, mid and right upper zone. The patient was given empirically broad-spectrum antibiotics (piperacillin-tazobactam and amikacin) with bronchodilators. A CT of thorax was performed which revealed multiple cavitary consolidations in bilateral lung parenchyma with the largest measuring 6 x 4 cm in left lower lobe (Fig. 1, B, C, D). CT thorax also showed Centrilobular pulmonary micro-nodules noted predominantly in right upper, bilateral lower lobe.
For the initial 7 days, our patient did not respond with progressive worsening of respiratory symptoms. Repeated blood cultures were sterile. Sputum for modified acid-fast gram staining (1% sulphuric acid) revealed long, branching, filamentous acid-fast bacilli suggestive of Nocardia species (Fig. 2). Lacto-phenol cotton blue (LPCB) mount staining of sputum showed hyaline septate hyphae, conidiophore with oval vesicle, and biserriate phialide with a chain of conidia suggestive of Aspergillus species (Fig. 3, A, B). By 9th day of admission, the fungal culture grew Aspergillus terreus. Subsequently, delayed growth of Nocardia species from bronchoalveolar lavage fluid was also confirmed by day 14. Galactomannan testing of bronchoalveolar lavage fluid was found to be positive, which further consolidate the presence of pulmonary Aspergillosis. After confirmation of Co-infection of Aspergillosis and Nocardiosis, our patient was started on oral Trimethoprim-sulfamethoxazole (480 mg/2400 mg) per day in divided doses. In a view of invasive pulmonary Aspergillosis, voriconazole (200 mg twice a day) was also added. Within a week of starting Trimethoprim-sulfamethoxazole and voriconazole, the patient became symptomatically well and discharged. At one month of follow-up, the patient became asymptomatic with antifungal and Cotrimoxazole were planned to be continued for further 6 months.