Concurrent pulmonary infection with Nocardia spp. and Mycobacterium tuberculosis in an adult with cerebral palsy: a case report

Nocardiosis is a rare opportunistic infection typically affecting immunocompromised individuals and those with chronic lung disease, prolonged corticosteroid therapy, malignancy, or other conditions impairing cell-mediated immunity, while tuberculosis (TB) remains a leading global health concern. Dual infections with Nocardia and TB are rare but clinically important, as overlapping clinical and radiologic features make diagnosis difficult. Reports have also documented co-infections with Nocardia and other pathogens, including Aspergillus and nontuberculous mycobacteria, underscoring the diagnostic complexity of these infections. We describe a 43-year-old man with cerebral palsy and a history of psychiatric illness who presented with fever, cough, dyspnea, generalized weakness, and imbalance. Non contrast Chest computed tomography (CT) revealed a large cavitary lesion with collapse-consolidation and multiple nodules in the right lower lobe. Bronchoscopy with bronchoalveolar lavage (BAL) demonstrated acid-fast bacilli (AFB) on Ziehl–Neelsen stain and partially acid-fast branching rods, and a multiplex real-time PCR assay on BAL fluid confirmed coinfection with Nocardia spp. and TB. The patient received a combination of imipenem, linezolid, levofloxacin, and high-dose trimethoprim–sulfamethoxazole together with standard anti-tubercular therapy, along with supportive management for seizures and lung abscesses. Coexisting pulmonary nocardiosis and TB, though uncommon, poses significant diagnostic and therapeutic challenges. This case highlights the importance of maintaining high clinical suspicion, particularly in patients with comorbidities or immune dysfunction, and demonstrates the value of combining conventional staining with molecular methods for accurate and timely pathogen identification. Early recognition of dual infections is critical to initiate appropriate therapy, reduce morbidity, and improve outcomes. Appropriate management includes standard 6-month anti-tubercular therapy combined with nocardial-directed treatment of variable duration, often shorter in immunocompetent patients whereas disseminated disease or immunocompromised hosts may require up to 12 months.