A complicated case of an immunocompetent patient with disseminated nocardiosis

Abstract

Nocardia species are aerobic, gram positive filamentous branching bacteria that have the potential to cause localized or disseminated infection. Nocardiosis is a rare disease that usually affects immunocompromised patients and presents as either pulmonary, cutaneous or disseminated nocardiosis. Forty-two year-old hispanic male presented to our care with bilateral lower extremity weakness, frontal headache, subjective fever, nausea, and vomiting. Brain computed tomography (CT) revealed multiple hyperdense lesions with vasogenic edema in the frontal, parietal and left temporal lobes. Chest CT demonstrated bilateral cavitary nodules in the lung and right hilar lymphadenopathy. Brain magnetic resonance imaging revealed multiple bilateral supratentorial and infratentorial rim enhancing lesions involving the subcortical gray-white matter interface with vasogenic edema. Patient was started on empiric therapy for unknown infectious etiology with no response. He eventually expired and autopsy findings revealed a right hilar lung abscess and multiple brain abscesses. Microscopic and culture findings from tissue sample during autopsy revealed nocardia wallacei species with multidrug resistance. The cause of death was stated as systemic nocadiosis (nocardia pneumonitis and encephalitis). The presence of simultaneous lung and brain abscesses is a reliable indication of an underlying Nocardia infection. An increased awareness of the various presentations of nocardiosis and a high index of clinical suspicion can help in a rapid diagnosis and improve survival in an otherwise fatal disease. This case highlights the importance of obtaining a tissue biopsy for definitive diagnosis on the initial presentation when an infectious process is considered in the differential diagnosis and early treatment can be initiated.

Pulmonary Nocardiosis Misdiagnosed as Tuberculosis

“…is opportunistic pathogens of immune compromised patients [9,10]. No source of infection could be detected in the current case as Nocardia are found in environment worldwide in fresh and salt water and soil type, dusts and fecal deposit of animal [11].…”

Nocardial Cerebellar Abscess in an Immunocompetent Male - A Case Report

“…Gram stain showing filamentous branched gram positive bacilli is the most sensitive method for diagnosis. Further it can be seen as acid fast structures in MAFS [3] .…”

“…No randomized trials have been performed to determine the most effective antibiotic regimen for nocardiosis. However, trimethoprim-sulfamethoxazole is considered the mainstay of therapy since most studies have shown a favorable susceptibility to this antibiotic [3] . CNS nocardiosis usually results after pulmonary nocardiosis but pulmonary infection or other focus of infection could not be substantiated in this patient at the time of admission.…”

“…Cerebral abscess of Nocardia carries considerably higher mortality rates of 55% and 20% in immunocompromised and immunocompetent patients, respectively [5] . If left untreated, disseminated nocardiosis has a mortality rate of greater than 85% [3] . …”

“…Immunocompetent patients usually develop localized cutaneous lesions such as cellulitis, abscesses, sporotrichoid forms of infections [2] . Immunocompromised patients present as pulmonary, cutaneous or disseminated nocardiosis [3] . Disseminated disease is defined by the presence of two or more organs infected by Nocardia and is characterized by hematogenous spread of microbes into brain, eye, bone, joint, heart, kidney, skin or other organs and tissues.…”