Pulmonary nocardiosis masquerading as refractory haemoptysis in a bronchiectasis patient: the critical role of multidisciplinary management

An immunocompetent male in his 30s with a history of bronchiectasis presented with recurrent haemoptysis (5–10 mL every 2 months) over 4 years. High-resolution CT revealed cystic bronchiectasis and ground-glass opacities. Bronchoscopy identified active bleeding from a ruptured bronchial artery, which was successfully managed with emergent embolisation. Bronchoalveolar lavage demonstrated weakly acid-fast branching filaments, later confirmed as Nocardia asteroides by matrix-assisted laser desorption-ionisation time of flight mass spectrometry. The patient responded well to trimethoprim-sulfamethoxazole and remained stable at follow-up. This case highlights three key points: (1) pulmonary nocardiosis should be considered in chronic haemoptysis, especially in patients with structural lung disease, even if immunocompetent; (2) rapid microbiological diagnosis is critical, particularly when acid-fast staining yields atypical results; and (3) bronchial artery embolisation can be lifesaving in cases of nocardial vasculitis with active bleeding. The report underscores the importance of multidisciplinary management in such complex presentations.