Disseminated Nocardiosis With Perimyocardial Involvement

Nocardia pseudobrasiliensis causes opportunistic infection in immunocompromised hosts. Cardiac involvement is rare and may mimic malignancy or inflammatory disease.

A 44-year-old woman with prior liver and kidney transplantation on immunosuppressants presented with pleuritic chest pain, cough, and subcutaneous nodules. Electrocardiogram showed diffuse ST-segment elevation and PR depression. Cardiac magnetic-resonance imaging revealed a heterogeneously enhancing left ventricular apical and anterior septal mass with extension into the right ventricle, along with pericardial thickening, and chest computed tomography demonstrated cavitary pulmonary nodules and a periscapular abscess. Aspiration of the periscapular abscess confirmed disseminated nocardiosis. She was treated with intravenous imipenem and trimethoprim-sulfamethoxazole with a steroid taper, resulting in clinical and radiographic improvement.

This case illustrates a rare infectious cause of a myocardial mass and perimyocarditis identified through multimodality imaging, highlighting the importance of maintaining a broad differential diagnosis in transplant recipients presenting with infectious symptoms.

Nocardiosis and infection with other atypical organisms should be considered in immunosuppressed patients with cardiac masses to elucidate etiology early and target antimicrobial therapy to improve patient outcomes.