Citation: Ghosh S, Pal D, Pal S, Roy J and Bhakta A. An Unusual Presentation of Nocardiosis - A Report of Two Cases. Austin J Trop Med & Hyg. 2015;1(2): 1006. Austin J Trop Med & Hyg - Volume 1 Issue 2 - 2015 ISSN: 2472-3681 | www.austinpublishinggroup.com Pal et al. © All rights are reserved Austin Journal of Tropical Medicine & Hygiene Open Access Abstract Nocardiosis is an opportunistic infection more common in immune compromised hosts. Disseminated nocardiosis has a poor outcome. We report a case of disseminated nocardiosis with nocardaemia (case-1) which is an extremely rare inding even in immune compromised subjects. In case-2 we found pulmonary abscess caused by nocardia in a patient of sarcoidosis on steroids. Vascular thrombosis complicating nocardiosis is not recognized. We report two cases of nocardiosis with arterial thrombosis. Keywords: Immunocompromised state; Disseminated nocardiosis; Cerebral abscess; Pulmonary abscess; Vascular thrombosis He presented with foot drop in another institution four months before where he was diagnosed as having mononeuritis multiplex based on NCV/EMG study showing bilateral peroneal neuropathy. His connective tissue panel (Anti-nuclear antibody etc.) and vasculitis screening (ANCA) were all negative at that time. He was started on oral cyclophosphomide (50 mg/day) and prednisolone (40mg/ day) for mononeuritis multiplex in that institute with signiicant improvement of his muscle strength and became ambulatory. He was also on oral anticoagulant therapy following a massive pulmonary thromboembolism which he sufered few weeks ater starting immunosuppressive therapy (Figure 1). At the time of admission, he was receiving prednisolone-40mg/day, cyclophosphomide-50mg/ day, oral anticoagulant and calcium supplement. Examination of the respiratory system revealed tachypnoea and coarse crackles in right infrascapular area. Neurological examination revealed wasting of proximal and distal muscles of both lower limbs with muscle power of 4/5 in all groups. Deep tendon relexes were preserved except let knee jerk. Sensory system, cranial nerves and cerebellar functions were all normal. Introduction Nocardia species are saprophytic aerobic actinomycetes and are common worldwide in soil causing decay of organic matter. It is an opportunistic pathogen causing signiicant morbidity and mortality in human beings. It predominantly afects lung with pre-existing structural defects and also with co-existing mycobacterial infection. Disseminated nocardiosis occurs through haematogenous spread to distant organs including brain (commonest), bone, sot-tissues and kidney; whereas peritoneum and heart valves only rarely afected. Isolating nocardia in blood culture (nocardaemia) is extremely rare [1]. Endovascular foreign body [2] e.g. prosthetic heart valve is a unique risk factor for nocardaemia but our patient (case I) did not posses any such foreign body. Nocardia bacteraemia is also associated with simultaneous infection with other bacterial pathogens, especially Gram negative organisms in 30% [2]. First patient had concomitant Klebsiella infection [Extended-Spectrum Beta-Lactamase (ESBL) producer] in lung. Surprisingly in both the cases vascular thrombosis complicated the picture-thrombosis in pulmonary trunk was in case- 1 and lacunar infarcts of brain found in case-2. Nocardiosis and vascular thrombosis may be causally related. Case Report Case I A 52 yr old gentleman presented to our clinic with fever and dry cough for 15 days. He also complained of chest tightness and exertional breathlessness for the same duration. His fever was low grade, intermittent in nature and subsided only on taking antipyretics. It was associated with cough without expectoration, hemoptysis or chest pain. He had a signiicant past history. Ten years ago he was treated for pulmonary tuberculosis. Case Report An Unusual Presentation of Nocardiosis - A Report of Two Cases Subhasish Ghosh 1 , Dipankar Pal 2 *, Shekhar Pal 3 , Jayanta Roy 4 and Arpita Bhakta 5 1 Consultant Pulmonologist, Apollo and AMRI Hospitals, Kolkata, India 2 RMO cum Clinical Tutor, Dept.of Tropical Medicine, School of Tropical Medicine, Kolkata, India 3 Assistant Professor, Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India 4 Consultant Neurologist, Department of Neurology, Apollo Hospitals, Kolkata, India 5 Head of the Dept.of Microbiology, AMRI Hospitals, Kolkata, India *Corresponding author: Dipankar Pal, RMO cum Clinical Tutor, School of Tropical Medicine, India Received: December 18, 2014; Accepted: February 17, 2015; Published: February 19, 2015 Figure 1: CT Pulmonary Angiography showing saddle embolus.