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Case 1

A 42-year-old male presented with fever, productive cough with episodes of hemoptysis and breathlessness from one week, and altered sensorium and tremors for 3 days. He was a chronic alcoholic, with a history of binge drinking for 1 month and stopped for 3 days. He did not have any other significant past, personal, or drug history. On examination, he was conscious but drowsy. He was febrile with a body temperature of 1020 F, pulse rate was 124beats/min, respiratory rate was 28 cycles/min and Blood pressure was 114/70mmHg. His O2 saturation was 88%. On systemic examinations, fine crepitations were heard in all the areas of the right lung. Other systems examination was unremarkable. His blood investigations revealed TLC17,250cell/mm3. Other investigations (Hb, platelet count, RBS, RFT, LFT, FBS, PPBS, HbA1C) were normal. VCTC was negative. Chest x-ray showed non-homogenous opacities, infiltrations, and two thin-walled cavities in the right lung upper and middle zone. (fig.1) Differential diagnosis of community-acquired pneumonia or pulmonary tuberculosis in alcohol withdrawal state was made and the patient was started on Inj.Linezolid(600mg bid), Inj.meropenem (1g tid) and bronchodilators. 4hrs after admission, the patient became tachypneic and his oxygen saturation was not maintained on an oxygen face mask. Then the patient was intubated and kept on a ventilator. Despite broad-spectrum antimicrobial therapy, the patient’s condition was deteriorating. ATT was planned to start but several sputum samples collected and tested for the presence of acid-fast bacilli were negative. Sputum for GeneXpert was also negative. Sputum Gram stain revealed Gram-positive thin branching filaments (figure 2). Modified Ziehl-Neelsen staining showed branching Acid-fast bacilli consistent with the morphology of Nocardia species(Figure 3). Culture and sensitivity of tracheal aspirate identified the organism as Nocardia. Tablet Cotrimoxazole (160/800mg DS tablets bd) was added to meropenem. The patient improved clinically and radiologically and was discharged after 15 days and advised to continue Cotrimoxazole for 9 months. The patient is coming for a follow-up and is doing well.