case_images: PMC11806675_01
case_images: (A): Nodule in the upper lobe of the left lung (black arrow), showing blurred boundaries with slight pleural effusion on the left side. (B): Left upper lung subpleural nodule (black arrow), diameter 2.2 cm, with visible lobulation and limited pleural effusion on both sides. (C): Nodule in the middle lobe of the right lung (black arrow), with small amount of pleural effusion on both sides and bronchiectasis in both lower lungs.
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case_images: Chest computed tomography (CT) scan shows a small amount of pleural effusion on both sides (Figure 1), multiple nodules in the upper lobe of the left lung (Figure 1A and B), and the middle lobe of the right lung (Figure 1C).  
case_images: (A): CT image of the lung window shows patchy high-density shadows in both upper lobes, the formation of a thick-walled cavity in the upper right lobe (white arrow), and pleural effusion on the left side. (B): CT image of the lung window shows an increase in the mass shadow adjacent to the left pulmonary hilum relative to the previous scan, accompanied by an increase in the left pleural effusion, relative to the previous scan. (C): CT image of the lung window shows multiple patchy high-density shadows in both lungs, with some cavity formation (white arrows) and uneven thickening of the walls. (D): CT image of the lung window shows consolidation in the left lingual lobe and lower left lobe, together with an increase in pleural effusion on the left side relative to the previous scan.
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case_images: Four weeks later, enhanced chest CT scans indicated worsening of the lung lesions and a significant increase in the pleural effusion in the left lung (Figure 2), together with multiple patchy high-density shadows in both lungs (Figure 2) and partial cavity formation (Figure 2A-C).
case_images: Appearance of the pleural effusion, showing purulence and a reddish-brown color.
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case_images: A thoracic drain was placed in the patient, yielding a purulent reddish-brown fluid (Figure 3), later confirmed as empyema.
case_images: (A): Smear cultures of sputum specimens, showing their appearance as clusters of filamentous Gram-positive bacteria (indicated by arrows) with bead-like bacterial cells under oil microscopy (10 *100x). (B): Weak acid-fast-bacteria positivity of the sputum specimen with filamentous bacteria (indicated by the arrow) under oil microscopy (10 * 100x). (C): Identification of the pathogen as Nocardia otitidiscaviarum by mass spectrometry using a VITEK   system.
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case_images: Gram staining of sputum smears showed positive bacilli (Figure 4A) and acid-fast-bacterial staining showed weak positivity (Figure 4B), Finally, after culture on Columbia blood agar medium, the VITEK test   and mass spectrometry identified the Nocardia otitidiscaviarum (Figure 4C).