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+A 58-year-old cotton farmer was presented to the West China Hospital of Sichuan University because of an over 1-month history of recurrent fever (between 38 and 40 °C), productive cough, and dyspnea.
+Prior to admission, he was diagnosed of pneumonia and treated with latamoxef, ofloxacin, vancomycin, and voriconazole at local hospital.
+However, no remission of symptoms was observed.
+Moreover, he was a hepatitis B virus carrier with a 10 pack-years smoking history.
+However, no history of diabetes mellitus, tuberculosis, and use of glucocorticoids in the past were informed.
+On admission, blood pressure, 145/95 mm Hg; heart rate, 120 per minute; respiratory rate, 30 per minute; and temperature, 39.3 °C.
+Physical examination revealed diminished breath sounds, but no rales were heard, and evaluation of other systems was unremarkable except moderate edema of lower limbs.
+Arterial blood gases analysis showed pH 7.361, PCO2 53.5 mm Hg, and PO2 62.8 mm Hg.
+Laboratory data (Table ​(Table1)1) revealed leukocytosis of 49,500/mm3 with 97.4% neutrophils, and elevated procalcitonin of 5.16 ng/mL.
+Chest computed tomography, presence of nodules, masses, patchy consolidations, and bilateral pleural effusion, is noted (Fig.1A).
+Meanwhile, it was soon alerted in sputum smear with presence of filamentous, gram-positive, weakly acid-fast, and beaded bacilli with possible diagnosis of Nocardia infection (Fig.1B, C).
+Trimethoprim-sulfamethoxazole (3 pills per 6 hours) with noninvasive ventilation was promptly administered.
+Sputum culture showed growth of numerous bacteria that were precisely determined to be N otitidiscaviarum by the method of mass spectroscopy on day 6 after admission (Fig.1D).
+Antibiotics were thus modified to amikacin and imipenem in addition to trimethoprim-sulfamethoxazole in accordance with the sensitivity test.
+However, the patient was not improved as expected and eventually died from severe respiratory insufficiency on the 13th hospital day.