Case Report of Nocardial Brain Abscess in a Patient on Steroids

Abstract

Nocardial brain abscesses are a rare cause of cerebral abscesses that usually arise in immunocompromised patients and are associated with high morbidity and mortality. We present the case of a 57-year old male who presented with fever, progressive vision loss and disorientation in the emergency room while on treatment for community acquired pneumonia. He has been using steroids for 20 years and has uncontrolled diabetes mellitus, and secondary adrenal insufficiency as a result. Chest computed tomography (CT) showed consolidation in left posterior-inferior lobe. Blood and cerebrospinal fluid (CSF) cultures were negative. Magnetic resonance imaging (MRI) of the head revealed multiple small dispersed lesions with peripheral ring enhancement after contrast administration, concerning for abscesses. Pus was sampled from a superficial occipital abscess and content grew Nocardia sensitive to trimethoprim/sulfamethoxazole (TMP/SMX) and imipenem so the patient was switched to targeted therapy. The following days he developed new motor deficits and became unresponsive to verbal stimulus. Another MRI revealed enlargement of the existing lesions and new lesions with signal restriction on diffusion (DWI) in the levels of the midbrain and pons. The patient developed respiratory insufficiency and passed away regarding of ongoing supportive treatment.