Nocardia empyema in an immunocompromised host: A case report

Patients with myeloproliferative disorders such as primary myelofibrosis are at an increased risk of opportunistic infections including <i>Nocardia</i> pneumonia. <i>Nocardia</i> can become disseminated with the central nervous system being the primary site affected although any organ system can be involved. Here we present a case of <i>Nocardia</i> empyema, a rare and sparsely documented location of infection, in a post matched unrelated donor hematopoietic cell transplant patient. Further complicating this case was the presence of fungal pneumonia in the right lower lobe that led to delayed diagnosis of <i>Nocardia</i> pneumonia and empyema as non-resolving nodular opacities were thought to be worsening fungal pneumonia. This case highlights the difficulties in diagnosing <i>Nocardia</i> infections, the limitations of our diagnostic tools, the atypical presentation of empyema in an immunocompromised host, and Hickam's dictum; the idea that a patient can have multiple diagnoses occurring simultaneously.