Concomitant pulmonary infection with Nocardia transvalensis and Aspergillus ustus in lung transplantation Miguel M. Cabada, MD, a Shawn P. Nishi, MD, b Alfred S. Lea, MD, a Vicki Schnadig, MD, c Gisele A. Lombard, RN, d Scott D. Lick, MD, e and Vincent G. Valentine, MD, FACP d From the Divisions of a Infectious Diseases and b Pulmonary, Allergy and Critical Care, c Department of Pathology, d Texas Transplant Center and e Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, Texas, USA. Lung infections with Nocardia and Aspergillus spp in lung transplant recipients (LTRs) create diagnostic and therapeutic challenges. The present case illustrates the difficulties in identifying these pathogens in LTRs. A high degree of clinical suspicion and aggressive early management are required to ensure good outcomes. Although prospective data on treating these conditions are scarce, the empiric use of combination broad-spectrum anti-microbials initially seems prudent. J Heart Lung Transplant 2010;29:900 –3 © 2010 International Society for Heart and Lung Transplantation. All rights reserved. KEYWORDS: Nocardia; aspergillus; opportunistic pathogens; lung transplantation; resistant organisms Survival after lung transplantation has improved little despite advances in surgical techniques, immunosuppres- sion and opportunistic infection management. According to the registry of the International Society for Heart and Lung Transplantation, non-cytomegalovirus infections are among the most common causes of death in lung transplant recipients (LTRs), especially in the first year, and significantly contribute to overall morbidity and mor- tality. 1 Concomitant opportunistic infections in LTRs are well described. One report noted 7 of 11 LTRs with Nocardia spp lung disease had at least one co-infecting organism, with Aspergillus spp accounting for 27%. 2 A similar report described 6 of 10 LTRs with Nocardia spp pulmonary disease co-infected with Aspergillus spp, of whom half had an additional pathogen isolated. 3 In this report we describe the clinical presentation, diag- nostic strategy and therapeutic approach to pneumonia caused by synchronous Aspergillus ustus and Nocardia transvalensis in a LTR. A review of key clinical and epi- demiologic characteristics of both opportunistic pathogens is summarized. Case report A 65-year-old Hispanic man with idiopathic pulmonary fibrosis underwent right single-lung transplantation. The recipient and donor were seropositive against cytomegalovi- rus. Induction immunosuppression consisted of equine anti- thymocyte globulin followed by maintenance tacrolimus, azathioprine and prednisone. Anti-microbial prophylaxis consisted of trimethoprim–sulfamethoxazole (TMP-SMX) given 3 times weekly and valganciclovir and itraconazole given daily. His lung function and clinical symptoms steadily improved. Five months after transplantation he developed progres- sive anorexia, dyspnea and a productive cough with a com- mensurate decline in lung mechanics and 6-minute walk distance. High-resolution computed tomography (HRCT) of the thorax showed right middle and lower lobe nodular opaci- Reprint requests: Vincent G. Valentine, MD, Texas Transplant Center, University of Texas Medical Branch, 4.140 John McCullough Building, 301 University Boulevard, Galveston, TX 77555-0772. Telephone: 409- 772-3115. Fax: 409-747-1901. E-mail address: vgvalent@utmb.edu http://www.jhltonline.org 1053-2498/$ -see front matter © 2010 International Society for Heart and Lung Transplantation. All rights reserved. doi:10.1016/j.healun.2010.04.016