Cerebral Nocardiosis Caused by N. brasiliensis, a Nocardial Species That Commonly Causes Skin Infection

1Carilion Clinic, Roanoke, VA
2Carilion Clinic, Roanoke, VA

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 142

Case Presentation:

A 44‐year‐old woman with history of SLE on chronic prednisone presented to the ED with complaints of severe headaches and neck stiffness. A CT scan revealed acute communicating hydrocephalus and bilateral cerebellar lesions. Shortly after admission, she became acutely obtunded. Emergency ventriculostomy was performed, and she was stabilized. AN MRI showed diffuse meningeal enhancement, with bilateral ring‐enhancing cerebellar lesions. CSF was hazy, with WBC 7, RBC 1045, protein 62, and glucose 113. It was negative for AFB, HSV, and toxoplasmosis. HIV testing was negative. An initial chest radiograph was normal. The patient was started on broad‐spectrum antibiotics for meningitis. Because of the progressive hydrocephalus and enlargement of the lesions, she had a craniotomy and abscess drainage. Gram stain was suggestive of Nocardia. A specimen was sent to the Virginia State Laboratory for culture and to the CDC for susceptibility testing. Cultures of the specimen grew N. brasiliensis sensitive to trimethoprim/suifamethoxazole and cefepime. Despite adequate antimicrobial therapy and drainage, her mental status progressively declined and the ventriculostomy continued to drain large quantities of CSF. Because of her lack of improvement and new complications, care was withdrawn. Autopsy demonstrated multiple brain abscesses.

Discussion:

Nocardia is a saprophytic, filamentous organism that is ubiquitous in the environment. Most disseminated infections involve N. asteroides, N. nova, and N. farcicinia. In such cases, it is estimated that 85% of disseminated infections result as a consequence of primary pulmonary infections, N. brasiliensis is a less virulent species, found in warmer climates, and is typically associated with milder cutaneous infections. Here we report a case of infection from N. brasiliensis presenting as multiple brain abscesses and meningitis causing acute communicative hydrocephalus. Chronic steroid use was the cause of the patient's immunodeficiency in this case. Nocardiosis should always be considered in immunocompromised patients who present with cough, constitutional symptoms, or focal neurologic signs suggestive of intracranial pathology. Culture is the gold standard for diagnosis. Once considered, it is important to inform the local laboratory in order to lengthen the time of the culture, as culture may not be positive for up to 4 weeks of incubation. Further, the state health department and CDC should also be engaged to aid in diagnoses and susceptibility testing. Treatment includes long‐term antibiotic therapy with sulfa‐containing antimicrobials alone or in combination with other antimicrobials and as this case highlights, may be difficult to control.

Conclusions:

(1) Immunocompromised patients should initially be treated for common pathogens, but doctors should be very vigilant for uncommon pathogens. (2) When nocardiosis is considered, the laboratory should be notified to extend the culture for up to 4 weeks.

Author Disclosure:

D. De Leon, none; R. Wardrop, none; K. Belizaire, none.

To cite this abstract:

Belizaire K, Wardrop R. Cerebral Nocardiosis Caused by N. brasiliensis, a Nocardial Species That Commonly Causes Skin Infection. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 142. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/cerebral-nocardiosis-caused-by-n-brasiliensis-a-nocardial-species-that-commonly-causes-skin-infection/. Accessed June 17, 2019.

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