---
title: "Disseminated Trimethoprim/Sulfamethoxazole–Resistant Nocardiosis in a Renal Transplant Recipient"
id: "cdc-emerging-infectious-diseases-journal-3-disseminated-trimethoprim-sulfamethoxazole-resistant-nocardiosis-in-renal"
canonical_url: "https://medichelpline.com/clinical-feed/cdc-emerging-infectious-diseases-journal-3-disseminated-trimethoprim-sulfamethoxazole-resistant-nocardiosis-in-renal"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "CDC Emerging Infectious Diseases Journal"
source_url: "https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article"
published_at: "2026-10-15T04:00:00.000Z"
evidence_level: "Agency Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Disseminated Trimethoprim/Sulfamethoxazole–Resistant Nocardiosis in a Renal Transplant Recipient
## Provenance & Clinical Metadata
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- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** CDC Emerging Infectious Diseases Journal
- **Source URL:** [Original Journal Publication](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article)
- **Published At:** 2026-10-15T04:00:00.000Z
- **Evidence Rating:** Agency Feed
## Executive GIST (TL;DR)
- A 39-year-old renal transplant recipient on lifelong immunosuppression presented with 45 days of fever, hemoptysis, anorexia, and weight loss; initial chest CT showed right upper lobe consolidation and pleural effusion. - Lung biopsy culture grew **Aspergillus fumigatus** with a serum galactomannan of 8.16, meeting 2020 EORTC/MSG criteria for invasive pulmonary aspergillosis; voriconazole and liposomal amphotericin B were given but neurologic decline ensued. - Repeat lung biopsy demonstrated suppurative inflammation and weakly acid-fast, branching, beaded filamentous bacteria on Fite stain; tissue culture produced dry, chalky colonies consistent with **Nocardia** spp. - Species-level identification failed (MALDI-TOF unsuccessful twice; 16S rRNA sequencing unavailable). - Disk-diffusion susceptibility testing interpreted with Comité de l’Antibiogramme thresholds showed resistance to **trimethoprim/sulfamethoxazole** and ciprofloxacin, with susceptibility to linezolid, minocycline, imipenem, and amikacin. - Immunosuppression was reduced (tacrolimus and mycophenolate withheld; low-dose prednisone continued). Empiric imipenem plus linezolid was started with voriconazole; clinical improvement occurred within 1 week. - Linezolid was replaced by minocycline after 1 month because of cytopenias; imipenem was changed to meropenem because of seizure risk and continued for 3 months alongside minocycline. - At 6 months radiologic resolution of pulmonary and intracranial lesions occurred; graft function was preserved. The patient remained well at 1-year follow-up and continued secondary prophylaxis with minocycline. - The report emphasizes rising reports of **trimethoprim/sulfamethoxazole** resistance in **Nocardia**, substantial interlaboratory variability in susceptibility results, and diagnostic challenges including species identification limitations and the need for brain imaging in pulmonary nocardiosis due to frequent CNS involvement. - The source did not report species-level confirmation, 16S sequencing results, exact MIC values, or detailed dosing regimens beyond the named agents and treatment durations.
## Clinical Analysis & Structured Key Points
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[EID Journal](https://wwwnc.cdc.gov/eid/) 2. [Volume 32](https://wwwnc.cdc.gov/eid/early-release) 3. [Early Release](https://wwwnc.cdc.gov/eid/early-release#issue-1347) 4. [Main Article](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article) * [Facebook](https://www.facebook.com/sharer/sharer.php?u=%2Feid%2Farticle%2F32%2F11%2F26-0963_article "Share to Facebook") * [Twitter](http://twitter.com/share?url=%2Feid%2Farticle%2F32%2F11%2F26-0963_article&text= "Share to Twitter") * [LinkedIn](https://www.linkedin.com/shareArticle?url=%2Feid%2Farticle%2F32%2F11%2F26-0963_article&title= "Share to LinkedIn") * [Syndicate](https://tools.cdc.gov/medialibrary/index.aspx#/sharecontent//eid/article/32/11/26-0963_article "Embed this Page") [ Emerging Infectious Disease journal ISSN: 1080-6059 ](https://wwwnc.cdc.gov/eid/) _Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released._ #### Volume 32, Number 11—November 2026 ##### _Research Letter_ ### Disseminated Trimethoprim/Sulfamethoxazole–Resistant Nocardiosis in Renal Transplant Recipient, India On This Page [Research Letter](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article) * * * [Suggested Citation](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article) Figures [Figure 1](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f1) * * * [Figure 2](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f2) Downloads [RIS [TXT - 2 KB] ](https://wwwnc.cdc.gov/eid/article/32/11/26-0963.ris) Article Metrics [Metric Details](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article) Related Articles [Novel Macrolide-Resistant _M. pneumoniae_ Subclades](https://wwwnc.cdc.gov/eid/article/32/11/26-0439_article) * * * [Metastatic _Candidozyma auris_ Infection](https://wwwnc.cdc.gov/eid/article/32/11/26-0984_article) * * * [Five-Biomarker Definition for hvKp](https://wwwnc.cdc.gov/eid/article/32/11/26-0825_article) * * * [More articles on Antimicrobial Resistance](https://wwwnc.cdc.gov/eid/spotlight/antimicrobial-resistance) Sandeep Rao Kordcal, Md Tariq Maula, Vivek Malleshappa Suguna, Adil Rashid Khan, Rahul Ranjan, Stanzin Spalkit, Aruna Nambirajan, Gagandeep Singh, Neeraj Nischal, Immaculata Xess, and Manish Soneja[![Comments to Author](https://wwwnc.cdc.gov/eid/content/images/icon/email.gif)](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#comment) Author affiliation: All India Institute of Medical Sciences, New Delhi, India [Suggested citation for this article](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#suggestedcitation) ### Abstract A renal transplant recipient in India receiving trimethoprim/sulfamethoxazole prophylaxis experienced fever, hemoptysis, and neurologic deficits. The diagnosis was pulmonary aspergillosis and disseminated nocardiosis caused by trimethoprim/sulfamethoxazole–resistant _Nocardia_. Antimicrobial drug therapy led to complete clinical and radiological resolution after 6 months. This case highlights a resistant breakthrough _Nocardia_ pathogen in a transplant recipient. Renal transplant recipients on lifelong immunosuppression are at increased risk for opportunistic infections. Nocardiosis affects 0.04%–3.5% of solid-organ transplant recipients; pulmonary cases disseminate in up to 44% of cases, and central nervous system involvement occurs in 20%–44% ([_1_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r1 "1"),[_2_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r2 "2")). Concurrent infection with _Nocardia_ bacteria and _Aspergillus_ fungus accounts for only 5%–7% of posttransplant cases ([_2_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r2 "2")). Trimethoprim/sulfamethoxazole (cotrimoxazole) has been the mainstay of treatment and prophylaxis, but the rising prevalence of trimethoprim/sulfamethoxazole–resistant _Nocardia_ bacteria complicates empirical therapy and underscores the necessity of susceptibility testing for successful outcomes. Written informed consent for publication of this case report, including clinical details and accompanying radiological and histopathological images, was obtained from the patient; personal identifiers were withheld. Formal ethics committee approval was not required for a single case report according to institutional and journal guidelines. Figure 1 ![Histopathologic and radiologic findings in renal transplant recipient with disseminated trimethoprim/sulfamethoxazole–resistant nocardiosis, India. A\) High-resolution computed tomography of the chest before treatment, showing right-upper-lobe consolidation with adjacent passive atelectasis and a left pleural effusion. B\) Lung biopsy, Fite stained, showing weakly acid-fast, branching, beaded filamentous bacteria \(circle\). Original magnification ×1,000. C\) Lung biopsy, hematoxylin and eosin stained, showing suppurative inflammation \(arrows\). Original magnification ×400. D\) High-resolution computed tomography of the chest 6 months after treatment, showing resolution of the consolidation with residual pulmonary fibrosis.](https://wwwnc.cdc.gov/eid/images/26-0963-F1-tn.jpg) [Figure 1](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f1 "Figure 1"). Histopathologic and radiologic findings in renal transplant recipient with disseminated trimethoprim/sulfamethoxazole–resistant nocardiosis, India. A) High-resolution computed tomography of the chest before treatment, showing right-upper-lobe consolidation with adjacent passive atelectasis and... A 39-year-old woman who was taking tacrolimus, mycophenolate sodium, prednisolone, and trimethoprim/sulfamethoxazole prophylaxis after renal transplant had remained well for 14 months before experiencing fever, hemoptysis, anorexia, and weight loss over 45 days. High-resolution computed tomography of the chest revealed right upper lobe consolidation with pleural effusion ([Figure 1](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f1), panel A); lung biopsy culture grew _Aspergillus fumigatus_ , with a serum galactomannan result of 8.16 optical density index, confirming invasive pulmonary aspergillosis according to 2020 European Organization for Research and Treatment of Cancer and the Mycoses Study Group criteria ([_3_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r3 "3")). Despite the patient taking voriconazole and liposomal amphotericin B, altered sensorium and bilateral lower-limb weakness developed, leading to a higher center referral. Figure 2 ![Brain magnetic resonance imaging in renal transplant recipient with disseminated trimethoprim/sulfamethoxazole–resistant nocardiosis, India. A\) Diffusion-weighted image showing multiple foci of central diffusion restriction \(arrows\). B\) Apparent diffusion coefficient map showing corresponding signal change \(arrow\). C\) Axial T1-weighted postgadolinium image showing ring-enhancing supratentorial lesions \(arrow\). D\) Axial T2-weighted image showing lesions with central hyperintensity, a hypointense rim, and perilesional edema \(arrow\).](https://wwwnc.cdc.gov/eid/images/26-0963-F2-tn.jpg) [Figure 2](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f2 "Figure 2"). Brain magnetic resonance imaging in renal transplant recipient with disseminated trimethoprim/sulfamethoxazole–resistant nocardiosis, India. A) Diffusion-weighted image showing multiple foci of central diffusion restriction (arrows). B) Apparent diffusion coefficient map showing... Physical examination revealed asymmetric upper motor neuron weakness in the lower limbs, neck stiffness, and coarse bilateral crackles. Brain imaging revealed multiple ring-enhancing supratentorial lesions with central diffusion restriction and perilesional edema ([Figure 2](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f2)). Repeat transbronchial lung biopsy showed suppurative inflammation with weakly acid-fast, branching, beaded filamentous bacteria when Fite stained and stained with hematoxylin and eosin ([Figure 1](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f1), panels B and C). Tissue culture on Sabouraud dextrose agar grew dry, chalky colonies suggestive of _Nocardia_ spp., although species-level identification could not be confirmed because matrix-assisted laser desorption/ionization time-of-flight mass spectrometry failed twice and 16S rRNA sequencing was unavailable. We interpreted antimicrobial susceptibility by disc diffusion on cation-adjusted Mueller–Hinton agar by using Comité de l’Antibiogramme de la Société Française de Microbiologie thresholds; the organism appeared resistant to cotrimoxazole and ciprofloxacin and susceptible to linezolid, minocycline, imipenem, and amikacin ([_4_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r4 "4")). A diagnosis of disseminated trimethoprim/sulfamethoxazole–resistant nocardiosis with pulmonary and cerebral involvement was made. Tacrolimus and mycophenolate were withheld, low-dose prednisone was continued, and imipenem and linezolid were initiated alongside voriconazole; clinical response was noted within 1 week. After 1 month, cytopenias developed, and linezolid was switched to minocycline. Because of seizure risk, imipenem was changed to meropenem, and the patient was continued on meropenem for 3 months with minocycline. Voriconazole was stopped after 6 months. Imaging at the end of 6 months confirmed radiological resolution in both intracranial and pulmonary lesions, with preserved graft function ([Figure 1](https://wwwnc.cdc.gov/eid/article/32/11/26-0963-f1), panel D). The patient continued to do well at 1-year follow-up and remains on secondary prophylaxis with minocycline. Trimethoprim/sulfamethoxazole resistance in _Nocardia_ bacteria is increasingly reported worldwide, although prevalence varies considerably with isolate source, geographic region, and the susceptibility method used. Susceptibility testing is also technically demanding and might be affected by the lack of control strains of _Nocardia_ spp. with known susceptibility patterns. One study found that 42% of United States isolates appear resistant to trimethoprim/sulfamethoxazole and 61% to sulfamethoxazole ([_5_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r5 "5")), whereas a separate study, comparing 552 isolates across 6 reference laboratories, reported only 2% resistance, attributing the difference in rates to inter-laboratory variability and possible misinterpretation of trailing MIC endpoints ([_6_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r6 "6")). Pulmonary infections remain a major cause of illness among postrenal transplant recipients, and opportunistic pathogens such as _Nocardia_ bacteria frequently coexist with fungal and mycobacterial disease, with overlapping radiological and clinical features that delay diagnosis in tropical countries. Reported resistance rates among cohorts in India have been of note. In a renal-transplant series of 16 nocardiosis cases, 9 patients were receiving trimethoprim/sulfamethoxazole prophylaxis, and 4 _N. farcinica_ isolates were resistant ([_7_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r7 "7")). In addition, a South India 10-year analysis reported 20.8% resistance among 48 cases ([_8_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r8 "8")), and a North India center reported nocardiosis in 12 (1.1%) renal transplant recipients, of which 60% isolates were trimethoprim/sulfamethoxazole–-resistant, and 7 of 12 patients (58.3%) had breakthrough infection while receiving prophylaxis ([_9_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r9 "9")). Brain imaging is indicated in all cases of pulmonary nocardiosis irrespective of neurologic symptom because of the 20%–44% rate of central nervous system involvement ([_1_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r1 "1"),[_2_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r2 "2")). Species-level identification remains a diagnostic challenge, because morphologic and biochemic methods are often inconclusive and the use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry might be limited ([_10_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r10 "10")). Disseminated nocardiosis carries a higher mortality rate of 64%–100% among transplant recipients ([_2_](https://wwwnc.cdc.gov/eid/article/32/11/26-0963_article#r2 "2")). This case report underscores the potential for breakthrough nocardiosis caused by trimethoprim/sulfamethoxazole–resistant isolates despite prophylaxis and highlights the importance of antimicrobial drug susceptibility testing to guide targeted therapy and optimize clinical outcomes. Dr. Kordcal is a clinical fellow in infectious diseases at the All India Institute of Medical Sciences, New Delhi, India. His academic and research interests include medical mycology, tuberculosis, and infections in immunocompromised hosts. [TopExternal Link](javascript:void\(0\)) ### Acknowledgments We thank the departments of medicine, radiology, microbiology, and pathology, All India Institute of Medical Sciences, New Delhi, India, for their assistance in the clinical care and diagnostic evaluation of this patient. The data supporting the findings of this study are avai
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