Nocardia Otomastoiditis in a Chemotherapy-Induced Neutropenic Patient With Diffuse Large B-cell Lymphoma: Successful Medical Management

Nocardia species are aerobic, filamentous, weakly acid-fast, Gram-positive bacteria. They cause opportunistic infections, particularly in patients receiving chemotherapy or corticosteroids. Otologic involvement is extremely rare, with only a few cases of Nocardia otomastoiditis reported worldwide. We report a 31-year-old woman with gastric and pancreatic diffuse large B-cell lymphoma who presented with fever and a one-week history of worsening purulent discharge from the left ear during chemotherapy-induced neutropenia. She had a 15-year history of intermittent otorrhea, previously treated with oral amoxicillin-clavulanate with transient improvement. On examination, she was febrile, with granulation tissue and purulent discharge in the left external auditory canal. Laboratory investigations confirmed neutropenia. Gram stain and modified Ziehl-Neelsen staining of the ear swab revealed beaded, branching, partially acid-fast filamentous organisms. Culture identified a Nocardia species susceptible to trimethoprim-sulfamethoxazole (TMP-SMX). Computed tomography (CT) imaging demonstrated otomastoiditis without bony erosion or intracranial extension. The patient was treated with a brief empiric course of intravenous imipenem, followed by eight weeks of oral TMP-SMX, resulting in the complete resolution of clinical symptoms and significant radiologic improvement. This case highlights the importance of considering Nocardia infection in patients with chronic or refractory otorrhea, particularly in the setting of chemotherapy-induced neutropenia. An early microbiologic diagnosis and focused therapy can lead to complete healing without surgery or long-term use of multiple drugs.