CTICasesNocardia Pulmonary Infection in Stem Cell Transplant Patient
Imaging findings
Chest radiograph shows a new small round density in the right upper lobe in a patient 14 months post-stem cell transplant with graft versus host disease on high-dose corticosteroids. CT confirms a right upper lobe nodule near the apex. The combination of stem cell transplant recipient status, GvHD, corticosteroid-mediated immunosuppression, neutropenia, and upper lobe nodule location is most consistent with an opportunistic fungal infection; however, this proved to be Nocardia.
Key takeaways
Nocardia pulmonary infection has a predilection for the upper lobes and produces CT findings indistinguishable from angio-invasive fungal infections including aspergillus — solitary or multiple nodules with or without cavitation. Risk factors overlap significantly with fungal infections: solid organ or stem cell transplant, corticosteroid therapy, and T-cell deficiency. Nocardia should be a routine member of the differential diagnosis for upper lobe nodules in the immunocompromised host, alongside aspergillus and cryptococcus. As this case demonstrates, the diagnosis requires culture from bronchoscopy or biopsy.
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