One-third of Nocardiosis occurs in immunocompetent individuals. The most common species in the United States are N. nova complex, N. brasiliensis and N. farcinica. We report a case of an immunocompetent patient with Covid-19 infection without steroid treatment, was co-infected by an uncommon Nocardia species, N. paucivorans resulted in countless brain abscesses. 

A 50-year-old, previously healthy white woman, who enjoyed gardening and composting, developed upper respiratory symptoms and headache one month prior to admission. She tested positive for COVID19 and was discharged from Emergency Department with doxycycline for suspected superimposed bacterial infection. She returned four days later with intermittent confusion, ten days later with worsening confusion and headache, then was transferred to our hospital. On admission, she was somnolent, oriented to self, and only following intermittent commands. There was no neck stiffness or skin rashes. She spontaneously moved all extremities with hyperreflexia throughout.

MRI revealed innumerable ring enhancing lesions with vasogenic edema throughout the brain and a few lesions in cervical cord. Work up identified no separate infections or reasons for an immunocompromised state except N. paucivorans positive in Karius panel, lung nodule, necrotic lymph node cultures, BAL PCR and brain tissue culture isolates. She was treated with multi-antibiotics and eventually down to Bactrim monotherapy. She was hospitalized for 27 days and discharged with improved mentation. Follow up MRI brain at 1, 3 and 6 months demonstrated decreased lesions and further clinical improvement.

It is reported that Nocardiosis can occur in patients several months after mild COVID-19 infection or severe Covid-19 infection with steroid treatment. Post-acute sequelae of Covid-19 (PASC) can occur several weeks after Covid-19 infection because it renders patients in a state of immunodeficiency. Co-infection of Covid-19 and an uncommon Nocardia species suggests possible alternative mechanisms, which highlights the need for further research.