An autopsy case of Nocardia meningitis patient presenting with multiple folliculitis

Abstract

Abstract Rationale: Nocardia is widespread in the soil and causes life-threatening infections in the central nervous system, such as meningitis. Nocardia infection can develop in immunocompetent individuals, not just in immunocompromised persons. Nocardia is a slow-growing bacterium, which makes its detection difficult during routine microbial examinations, resulting in a delayed diagnosis and poor prognosis. Patient concerns: A 64-year-old Japanese man was admitted with fever, headache with meningeal irritation, and multiple folliculitis on his face and neck. Cerebrospinal fluid revealed neutrophilic pleocytosis. All cultures, including cerebrospinal fluid examination, were negative, and serum procalcitonin levels were normal. Diagnoses: The tentative diagnosis was culture-negative bacterial meningitis or meningeal neuro-Behçet disease. Intervention: Meropenem was administered for 12 days, along with corticosteroids. His symptoms were temporarily relieved but worsened again, and finally, he died suddenly on the 37th day of hospitalization. An autopsy revealed extensive infiltration of inflammatory cells in the subarachnoid space, especially the brain stem, cerebellum, whole spinal cord, and cerebral base, where Nocardia species were detected. The final diagnosis was Nocardia meningitis. Lessons: Given the very close timing of the onset of signs of meningitis and multiple folliculitis, the most reasonable and probable idea is that the patient had disseminated nocardiosis. In patients with meningitis with multiple skin infection lesions, such as folliculitis, nocardiosis should be considered a differential diagnosis.