Nocardia is an opportunistic infection presenting similarly to various malignancies, bacterial, viral, and fungal infections. Predominant sites of infection include Pulmonary, Cutaneous, and Central Nervous System (CNS) - with CNS involvement often seen as slow-growing mass lesions with presenting neurological symptoms - its cure rate below 60%.

 54-year-old male with past medical history of smoking (15 pack/year), Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia who initially presented to an outside hospital with shortness of breath. Chest X-ray revealed consolidation of the right middle lobe. He was subsequently treated for Community Acquired Pneumonia.

He re-presented one month later with acute left sided facial droop, vertigo, binocular horizontal diplopia, and unsteady gait. Chest X-ray revealed airspace opacities in right upper lobe. T2- FLAIR MRI demonstrated multiple enhancing supra and infratentorial lesions; of note, mild/early mass effect due to lesion in the tegmentum of the pons. Lung biopsy findings suggested possible squamous cell carcinoma, resulting in whole brain radiation for possible brain metastasis and steroids for mass effect. Bronchioalveolar lavage culture returned 48 hours after intervention positive for Nocardia infection prompting transfer to our hospital.

Treatment was initiated with a synergistic combination of trimethoprim-sulfamethoxazole, imipenem and amikacin. He underwent multiple External Ventricular Drain (EVD) placements and replacements for persistent Hydrocephalus secondary to tract obstruction. He continued to decompensate exhibiting mental status changes, dysarthria, and nuchal rigidity. Lumbar puncture showed neutrophil predominance. Cultures were negative. T2- FLAIR MRI showed interval increase of edema surrounding areas of lesion. Family eventually opted comfort care. Postmortem findings revealed Nocardia Pneumonia, Parenchymal Abscesses, Meningitis, and Ventriculitis.

We present a case of disseminated Nocardia spp. where symptoms mirrored those of malignancy. Challenges exist in differentiating the two because of significant overlap between the presentation of bacterial infection, inflammation. underscoring the importance of a clear clinical timeline and diagnostic modalities.