Concurrent Nocardia Related Brain Abscess and Semi-Invasive Pulmonary Aspergillosis in an Immunocompetent Patient

Abstract

A 62-year-old woman presented with a 10-day history of headache and progressive right hemiparesis. There was no known underlying disease. A contrast-enhanced magnetic resonance imaging of the brain revealed rim enhancing lesions with associated edema located in the left cingulated gyrus and right parietal lobe (Fig. 1). A craniotomy was performed to drain the abscess. The obtained thick, yellow purulent material yielded Grampositive bacilli with branching fine filamentous forms, identified as Nocardia species. The fungus was not detected by culture technique using drained abscess fluid. Treatment with trimethoprim-sulfamethoxaole (TMP-SMX) was initiated post-operatively. During the post-operative management, two pulmonary nodules were detected incidentally ( Fig. 2A). We considered the pulmonary nodules to be nocardiosis at that time, and did not perform any further diagnostic procedures. After one month of INTRODUCTIONNocardia spp. was first described by Nocard in 1888 as a fungus and was further classified as a gram-positive, aerobic bacterium that belongs to the genus Nocardia, order Actinomycetales 4) . The central nervous system (CNS) is the most commonly involved site in disseminated nocardiosis. CNS involvement has been recognized in over 44% of all cases of systemic nocardiosis in one large study 1) . Nocardia cerebral abscesses are rare and generally occur in patients with defects in cell-mediated immunity. Nocardial abscesses account for 2% of brain abscesses and may occur as an isolated CNS lesion without evidence of extracranial disease, or as part of a disseminated infection in association with pulmonary or cutaneous disease 11) . Insidious presentations are often mistaken for neoplasia because of the paucity of clinical and laboratory signs of bacterial inflammation; the silent invasion and persistence make diagnosis and management more difficult. If a patient with cerebral nocardiosis has multiple pulmonary nodules, we presume that they reflect a pulmonary nocardiosis.Here, we report the first case of concurrent nocardial abscess and semi-invasive pulmonary aspergillosis in an immunocompetent patient. We describe here the first case of a concurrent brain abscess caused by Norcardia spp. and semi-invasive pulmonary aspergillosis in an immunocompetent patient. After one year of appropriate antimicrobial therapy and surgical drainage of the brain abscess, the nocardia brain abscess and pulmonary aspergillosis have resolved.

Nocardiosis of the Central Nervous System

“…A significant proportion of patients (15/84; 18%) had no comorbid conditions. 1 , 2 , 12 , 22 , 29 , 31 , 33 , 36 , 44 , 50 , 51 , 53 , 55 , 65 , 67 , 70 , 73 – 75 , 79 , 82 , 87 , 104 , 109 , 113 The most common comorbid condition was solid organ or bone marrow transplantation (25%). The kidney was the most commonly transplanted organ (n = 14), followed by liver (n = 3), heart (n = 2), bone marrow (n = 1), lung (n = 1), and allogeneic stem cell transplant (n = 1).…”

Magnetic Resonance Spectroscopy Findings of Pyogenic, Tuberculous, and Cryptococcus Intracranial Abscesses

“…The disease is generally associated with immunodeficient conditions. The imaging findings are generally similar to those of meningitis [20,21]. Parenchymal involvement occurs following the spread of the meningeal inflammation to the subarachnoid and ependymal surfaces.…”

NocardiaBrain Abscess in an Immunocompetent Patient

“…Nocardia brain abscess in an immunocompetent patient has rarely been reported [ 3 ]. In Korea, only one case of Nocardia brain abscess in an immunocompetent host has been reported [ 4 ]. We report an immunocompetent patient who had a Nocardia brain abscess, which was treated by stereotactic aspiration of the abscess and systemic antibiotics.…”