Abstract
Introduction Pulmonary recurrent nocardiosis is uncommon after lung transplantation, typically occurring within three years. Ultra-late presentations beyond a decade are exceptional and often coincide with chronic lung allograft dysfunction (CLAD) or prolonged immunosuppression. Case Description A 76-year-old woman with sarcoidosis, stage 3b chronic kidney disease, and bilateral lung transplantation 10 years earlier presented with hemoptysis. Imaging revealed a waxing-waning right-apical mass-like consolidation. Bronchoalveolar lavage cultures grew Nocardia wallacei resistant to imipenem and doxycycline but susceptible to ceftriaxone, amoxicillin-clavulanate, ciprofloxacin, and linezolid. She had a prior episode of Nocardia infection 12 months earlier treated with TMP-SMX until leukopenia and AKI necessitated a switch to ceftriaxone and ciprofloxacin followed by minocycline. Recurrent disease was treated with IV ceftriaxone plus ciprofloxacin for six weeks, then oral amoxicillin-clavulanate plus minocycline for three months, and maintenance minocycline monotherapy. DSA testing was negative, and restrictive CLAD was present. Subsequent CT imaging showed gradual resolution of the infection. Discussion Nocardia infections occur in 2-3 % of lung-transplant recipients, usually within three years. Ultra-late infection >10 years after transplant is rare and reflects persistent immune dysregulation and airway vulnerability from CLAD. Recurrence may represent relapse from residual organisms rather than reinfection. This case highlights the importance of long-term vigilance for opportunistic pathogens in CLAD patients and prolonged secondary suppression when TMP-SMX is contraindicated. This abstract is funded by: None