Mediastinal nocardiosis causing dysphagia/odynophagia: a case report

Nocardiosis is an uncommon but potentially life-threatening infection. It predominantly affects immunocompromised individuals or those with chronic lung diseases. The lungs are the most frequent focus of infection, followed by the skin and brain. Mediastinal nocardiosis remains exceedingly rare, with only a few cases reported in published medical literature. We report a case of a middle-aged man on chronic corticosteroids for autoimmune hemolytic anemia, who presented with dysphagia and odynophagia, with an apparently normal esophagogastroduodenoscopy, but with a mass/abscess abutting the esophagus on cross-sectional imaging, ultimately diagnosed with endoscopic ultrasound-guided aspiration yielding Gram-positive, acid-fast, branching filamentous rods, and culture confirmed Nocardia species. He was treated with intravenous imipenem and high-dose oral cotrimoxazole for 4 weeks, followed by prolonged oral cotrimoxazole therapy for 6 months, with an excellent clinical and radiological response. To our knowledge, this is the first reported case of mediastinal nocardiosis presenting with dysphagia/odynophagia, expanding the clinical spectrum of this rare infection and, highlighting the need for high clinical suspicion in immunocompromised patients with esophageal symptoms. With the rapid evolution of immunosuppressive therapies in the setting of neoplasia and organ transplantation, clinicians likely come across a myriad of manifestations of opportunistic infections, including nocardiosis. Multimodal imaging and advanced endoscopic techniques for tissue harvesting or aspiration facilitate the early recognition of these rare diseases and subsequent appropriate antimicrobial therapy, early enough for favorable outcomes.

The online version contains supplementary material available at 10.1007/s12055-025-02020-8.