Nocardial brain abscess: Need for rapid diagnosis and aggressive management

Abstract

Nocardiosis is an opportunistic disease that occurs commonly in immunocompromised patients and also sometimes in immunocompetent individuals. The most common disease sites include lung, skin and central nervous system (CNS). Nocardial brain abscesses are rare CNS infections with high mortality rate reaching 34% which is considered the highest amongst brain abscesses caused by microorganisms. We report two cases of nocardial brain abscesses in patients with pre-existing lung disease. The first case presented with seizures and the second with hemiparesis, hemianopia and pleural effusion. Magnetic resonance imaging (MRI) brain showed space occupying lesions, thought to be tuberculoma or malignant brain tumor. Per operatively they were found to be abscesses. The Gram stain of pus from both cases and cultures of pus and pleural fluid yielded Nocardia farcinica. Histopathology of brain tissue was also corroborative. Both patients were started on long term therapy of Sulphamethoxazole-Trimethoprim (Co-trimoxazole) and in the second case of disseminated nocardiosis, Ceftriaxone and Linezolid was added. These cases highlight the importance of including nocardial abscesses as differential diagnosis in immunosuppressed patients presenting with neurological deficits and abnormal MRI. Multisystem nocardiosis may not be as rare as assumed. Thus an increased vigilance towards diagnosis and appropriate treatment including surgical intervention is required for reducing morbidity and mortality.