Life-Threatening Nocardia Empyema: A Case Report

Purpose (a): To highlight a rare presentation of empyema and osteomyelitis of the ribs caused by Nocardia species bacteria. This case discusses the clinical features, imaging, and treatment of this unusual infection. Methods (b): A chart and literature review were performed with emphasis on disease presentation, imaging, cultures obtained, and treatment regimen involved in the management of osteomyelitis of the rib caused by Nocardia infection. The infection initially began as a pneumonia which was untreated due to the patient’s lack of health insurance coverage. The pneumonia then transformed into an empyema and eventually infiltrated the chest wall. This allowed bacteria to colonize in the rib causing an osteomyelitis that presented as a large subcutaneous mass of the chest. Results (c): The unusual clinical presentation of a large, painful, subcutaneous mass prompted a CT scan at the emergency department which identified an empyema in the lung and a rib fracture suggestive of osteomyelitis. Infectious etiology was confirmed with culture of both the rib and empyema aspirate, showing colonization with Nocardia. The patient was treated with aggressive IV Bactrim for 6 weeks followed by 4 weeks of oral Bactrim. At follow up he had complete resolution of symptoms. Conclusions (d): Adults with a history of untreated pneumonia who present weeks later with a large, subcutaneous mass on the thorax should be worked up for possible empyema and osteomyelitis of the ribs. In addition, it is important to obtain cultures and identify the correct infectious organism in order to ensure complete eradication of the infection.