Abstract
Introduction: Nocardia is a Gram-positive bacteria that usually cause opportunistic infections but can affect the immunocompetent host. The central nervous system can be the primary site of infection in up to 40% of the cases but the involvement of the spinal cord is extremely rare. Case Report: We present a case of a middle age man with history of alcoholic liver cirrhosis and diabetes mellitus who presented with acute lower back pain that is associated with right leg weakness and numbness. Magnetic resonance imaging (MRI) scan showed a spinal cord intramedullary abscess. The cerebrospinal fluid analysis was consistent with meningitis and the organism was eventually identified with CSF culture as Nocardia Farcinica. Patient was treated with prolonged intravenous trimethoprim/sulfamethoxazole and meropenem. No neurosurgical intervention was done and the patient had full neurological recovery in few months. Discussion: Nocardia species are able to cause different kinds of disease in man. Spinal cord abscess are extremely rare and high index of clinic suspicion is required for diagnosis. Initial combination intravenous antibiotics treatment is essential and should be continued for at least three to six weeks. Treatment can be switched to oral and continued for a minimum of six months. Surgical intervention might be indicated in some patients. 16s rRNA gene sequencing allows earlier identification and thus adjustment of antibiotics. Conclusion: This report illustrates that a diagnosis can be made by neuroimaging and cerebrospinal fluid (CSF) 16s ribosomalRNA sequencing, allowing early and effective antibiotic therapy and obviating the need for a high-risk neurosurgical intervention.
Highlights
Nocardia is a Gram-positive bacteria that usually cause opportunistic infections but can affect the immunocompetent host
The central nervous system can be the primary site of infection in up to 40% of the cases but the involvement of the spinal cord is extremely rare
The cerebrospinal fluid analysis was consistent with meningitis and the organism was eventually identified with CSF culture as Nocardia Farcinica
Summary
Nocardia is known to be ubiquitous in the environment and is able to cause different kinds of diseases in man, including skin and soft tissue infections, pneumonia, central nervous system (CNS) infection and bacteremia [1]. We present a rare case of such a neurological involvement as the initial presentation of Nocardia infection. A 53-year-old Caucasian male with past medical history of alcoholic liver cirrhosis, diabetes mellitus, and hypertension presented to the emergency department with acute onset lower back pain and inability to walk for two days He had numbness and weakness in the right leg, urinary retention and constipation. Given the high clinical suspicion, a magnetic resonance imaging (MRI) showed a signal abnormality and enhancement of the spinal cord, including the conus medullaris, consistent with intramedullary abscess (Figure 1). The CSF culture was finalized on day 20 of his admission and showed Nocardia farcinica, sensitive to TMP/SMX, amikacin, and imipenem, but resistant to ceftriaxone. Patient weakness started to improve slowly towards the end of his admission A six-month follow-up MRI scan showed resolution of the intramedullary abscess
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