A 75-year-old male was admitted to our hospital complaining of persistent fever with general malaise for approximately 1 week. The patient had a productive cough and his medical history showed that he had diabetes mellitus (HbA1C 9.2%), hypertensive cardiovascular disease, and chronic obstructive pulmonary disease. He used oral medication and an inhaled bronchodilator to control his aforementioned diseases. In the admission survey, a complete blood count revealed that the patient had leukocytosis (WBC 21,000 muL). Moreover, a biochemistry survey showed that he had an elevated C-reactive protein level (20.3 mg/dl). A chest X-ray revealed that his left upper lobe was consolidated. The blood culture and sputum culture were performed at the admission under the impression of pneumonia. First, intravenous third-generation cephalosporin (ceftriaxone) combined with macrolide (azithromycin) were used. The patient's clinical symptoms improved slowly, but he developed a high fever. A chest computed tomography (CT) performed 1 week later still showed left upper lung consolidation (Fig. 1). The bacteria laboratory then reported gram-positive bacilli growth in the patient's blood culture, and the acid-fast stain of the bacteria in blood specimen was also revealed to be positive. Nocardia spp. was highly suspected. We performed a bronchoscopy for the lung lesion, and multiple white cheese-like plaque coatings were observed over the left upper lobe bronchial orifice. The transbronchoscopy washing, brushing, and biopsy were performed. The sputum specimen direct smear showed acid-fast stain positive bacilli, and a biopsy specimen showed granulomatous inflammation. According to the blood culture data and bronchoscopy results, a Nocardia spp. pulmonary infection with sepsis was highly suspected. Hence, we changed the antibiotics to intravenous carbapenum (imipenem) and sulfonamide trimethoprim. The patient's clinical condition improved gradually. After 2 weeks, two sets of blood culture at admission finally showed Tsukamurella tyrosinosolvens. Moreover, three transbronchoscopy washing specimen cultures revealed Mycobacterium bovis 1 week later. We started isoniazid, rifabutin, and ethambutol treatment for the lung lesion immediately. The use of imipenem was 3 weeks and the sulfonamide and trimethoprim treatment was maintained for 1 month. Furthermore, the antituberculosis treatment was maintained for 12 months. After medical management, the patient's chest X-ray survey and physical condition markedly improved.
The chest CT shows left upper lung consolidation.