Diagnosing Disseminated Nocardiosis in a Patient With COVID-19 Pneumonia.

Signs and symptoms of atypical pneumonia include fever, shortness of breath, cough, and chest pain. During the coronavirus disease 2019 (COVID-19) pandemic, identifying other causes of febrile respiratory illness in patients who tested positive for COVID-19 has been very challenging. Concerns over infecting healthcare personnel and other patients can impede further evaluations like bronchial lavage, lung biopsies, and other invasive tests. A very high index of suspicion, perhaps unreasonably so, is required to perform invasive tests to investigate alternative possible causes of the illness. We present the case of a 63-year-old man who presented to the hospital with dyspnea. Chest X-ray demonstrated a consolidation in the left lower lobe lung field with a possible underlying mass, and the patient tested positive for COVID-19. He received the standard treatment for COVID pneumonia at the time in our institution (remdesivir and dexamethasone), empiric antibiotics for community-acquired pneumonia, and was eventually discharged home with supplemental oxygen. Several days later, the patient returned to the hospital again with worsening dyspnea and was readmitted. Persistent illness and worsening imaging prompted bronchoscopy. The bronchoscopy showed narrowing of the airway in the left upper lobe, and was isolated from bronchial aspirate. The isolation of Nocardia prompted an investigation for central nervous system involvement with an magnetic resonance imaging (MRI) of the head. The MRI demonstrated multiple bilateral ring-enhancing lesions in the brain. To our knowledge, this is the first reported case of disseminated nocardiosis superimposed on COVID-19 pneumonia.