Early diagnosis of disseminated nocardiosis in a case of pyomyositis and brain abscesses exemplifies the importance of smear examination.

We report a 73-year-old immunocompromised man with multiple muscle abscesses, in a toxic state with neurological deficits, with a history of panhypopituitarism, diabetes, hypothyroidism, and recent SARS-CoV-2 infection. MRI showed abscesses in the right chest wall, right thigh (peri-implant), and left adductor. Elevated inflammatory markers, comorbidities and clinical presentation suggested disseminated fungal or Nocardial infection. Immediate aspiration of the anterior chest wall abscess and protocolized sample collection identified Nocardial filaments in the smear within 4 hours, allowing for targeted antibiotic selection. Nocardia farcinica, an aggressive organism, was isolated on day 4. Brain MRI showed abscesses in the temporal lobe and brain stem. Debridement of the perimplant (total hip prosthesis) abscess and aspiration of left inguinal abscesses were performed. Targeted therapy with ceftriaxone, trimethoprim-sulfamethoxazole, and linezolid was started, with frequent adjustments due to adverse reactions. The patient improved significantly at 10 weeks, continued oral dual therapy for nine more months, and was maintained on chronic suppression with ciprofloxacin. At 26-month follow-up, the patient remained asymptomatic and recurrence-free. This case underscores the importance of a multidisciplinary approach and protocol-driven sample collection for early diagnosis and effective management of disseminated nocardiosis.