Nocardia asiatica Lymphadenitis in a Lung Transplant Recipient Following Travel

We report a case of lymphocutaneous nocardiosis in a 73-year-old male lung transplant recipient after traumatic soil exposure abroad. The patient traveled from Portugal to Brazil to undergo lung transplantation and, 3 months later, while receiving immunosuppressive therapy (with prednisolone, mycophenolate mofetil, and tacrolimus), sustained a nasal laceration after a fall onto soil-contaminated ground in Brazil. A persistent ulcerated facial lesion subsequently developed and was initially misdiagnosed as sporotrichosis, leading to treatment with itraconazole. Despite partial improvement, the patient later developed progressive bilateral parotid and submandibular lymphadenopathy. After returning to Portugal, imaging revealed necrotic cervical lymph nodes. Fine-needle aspiration specimens tested positive for Nocardia spp. by polymerase chain reaction, and Nocardia asiatica was isolated and identified by MALDI-TOF and 16S rRNA sequencing. Pulmonary and central nervous system involvement were excluded. Antifungal therapy was discontinued and trimethoprim-sulfamethoxazole initiated, resulting in progressive clinical improvement. This case underscores the importance of considering nocardiosis in transplant recipients with cutaneous lesions and lymphadenopathy after soil exposure, particularly in settings where other endemic infections may bias initial diagnostic assumptions, and emphasizes the importance of microbiological confirmation.