Chronic nocardiosis, Morgellons?

My lab is certified by CLIA and the College of American Pathologists for blood parasitology.  I examine blood for bloodborne parasites: Plasmodium (malaria), Babesia, Trypanosomes – flagellates, microfilaria. Today I became aware of a bacterium which may appear in the blood but is not bloodborne. Nocardia. I have a patient with this infection. I have been treating her for a long time.  We think Nocardia infection it is chronic along with tickborne pathogens. The bacterium is found in soil and water and is ubiquitous, there are numerous species, some not yet speciated/characterized. We (the patient and me) have thought she suffers with chronic nocardiosis.  She has a clear, documented history of Nocardia: positive pulmonary infiltrate and positive blood culture. This is a slow growing organism. Texts say this rarely seen organism cultures slowly, 3-5 days. Her culture was positive only after 28 days. Nocardia infections is thought to primarily occur in patients with impaired immunity. She lacked clear evidence of immune dysfunction. The bacteria forms lesions in the skin, lungs and brain. Generally, IV antibiotics are recommended initially followed by oral therapy. Standard sources say skin infection is always curable, lung infection is usually curable and brain infection is curable half the time. Texts don’t address chronic nocardiosis, but I haven’t done a literature search.

This bacterium takes on an unusual appearance.  We are accustomed to rods, cocci and spirochetes.  Microscopically these appear as fungal-like filamentous structures.  The filaments vary in length.  Over the years I seen similar things I thought they were contaminants or artifacts and most likely were (not using the same stain).  Perhaps I missed something.  Of course, this was not on my radar.  Images are startling. Images of clumped filamentous structures, looking not like bacteria at all but rather the dense threads seen with Morgellons appear. The images, if correct (I have not validated them) can be found on google images. I know for a fact that some images on google images are incorrect.

Then there are patient images of skin lesions of the cutaneous form of the disease. Some look horrible.  Some clearly resemble lesions seen with Morgellons.

The chest X rays and brain MRIs are distinct from those seen with tickborne disease.

Again, this organism is found on skin and in the lungs and brains. In severe cases it may also appear in blood, gram stains. I don’t know if it also appears in Giemsa stains I perform.

I wonder if some cases of Morgellons are misdiagnosed nocardiosis. I wonder if Lyme immunosuppression plays a role in the pathogenesis of the disease.  Antibiotics recommended are some of the same ones used for Lyme but not exactly the same ones. The initial early treatment recommended is IV Bactrim.