Case Report: Rare Presentation of Nocardia cyriacigeorgica Pleural Nocardiosis in a Kidney Transplant Patient

BACKGROUND: Nocardia species are gram-positive, filamentous bacteria causing opportunistic infections in immunocompromised patients. Nocardiosis in kidney transplant recipients is rare, with Nocardia cyriacigeorgica being an emerging pathogen first identified in 2001. CASE PRESENTATION: A 55-year-old male with end-stage renal disease underwent deceased-donor kidney transplantation with standard immunosuppression including tacrolimus, corticosteroids, and mycophenolate mofetil. Five months post-transplantation, he presented with cough, fever, and dyspnea. Initial chest computed tomography showed pleural effusion without consolidation. Despite percutaneous drainage and empirical antibiotics, symptoms persisted for 3 weeks. Repeat imaging revealed multiloculated pleural masses mimicking post-transplant lymphoproliferative disease. Surgical excision of the mass revealed inflamed granulation tissue, and cultures identified Nocardia cyriacigeorgica. Treatment was changed to intravenous imipenem/cilastatin and oral trimethoprim-sulfamethoxazole, with concurrent reduction of immunosuppression. The patient showed significant clinical improvement, with follow-up imaging demonstrating marked reduction in pleural masses. He was discharged after 10 weeks without graft dysfunction. CONCLUSION: This rare case of pleural nocardiosis caused by Nocardia cyriacigeorgica in a kidney transplant recipient highlights diagnostic challenges, as the presentation mimicked malignancy. High clinical suspicion is crucial when standard antimicrobial therapy fails in immunosuppressed patients. Early diagnosis through tissue culture and aggressive treatment with appropriate antibiotics, combined with immunosuppression adjustment, led to successful outcomes. This report adds valuable insights to the limited literature on this emerging pathogen in transplant recipients and emphasizes the importance of considering rare opportunistic infections in the differential diagnosis.