Ultrasound-guided thoracentesis for diagnosing Nocardia beijingensis-related empyema in a patient with systemic lupus erythematosus: A rare case report

Abstract

Infections caused by Nocardia species are relatively rare and primarily affect immunocompromised patients. There are few reported cases of Nocardia beijingensis causing empyema in patients with systemic lupus erythematosus (SLE). We present a case of a 49-year-old female patient with SLE on immunosuppressive therapy (corticosteroids and azathioprine), admitted with dyspnea and left-sided pleuritic chest pain. A diagnosis of large parapneumonic left pleural effusion was established based on blood tests, blind thoracentesis findings, and bronchoalveolar lavage results. The patient received empirical intravenous antibiotic therapy with imipenem/cilastatin and vancomycin without isolating the causative organism for 10 days. Three weeks postdischarge, the patient's left pleuritic chest pain worsened, prompting chest computed tomography that revealed multiple loculated pleural-abdominal wall fluid collections. Ultrasound-guided aspiration of these areas yielded pus cultured positive for N. beijingensis. The patient showed improvement following treatment with imipenem/cilastatin and trimethoprim/sulfamethoxazole. This case represents a rare manifestation of N. beijingensis causing pleural and abdominal wall empyema. Ultrasound-guided aspiration, targeting the loculated and encapsulated effusion, played a crucial role in confirming the diagnosis. Empirical treatment with imipenem/cilastatin combined with long-term oral trimethoprim/sulfamethoxazole was found to be effective.