Poster 154: Rare Case of Central Nervous System Nocardiosis in an Immunosuppressed Cadaveric Renal Transplant Patient: A Case Report

Abstract

Poster 154 Rare Case of Central Nervous System Nocardiosis in an Immunosuppressed Cadaveric Renal Transplant Patient: A Case Report. Erik C. Marsiglia, DO (Rush University Medical Ctr, Chicago, IL); Christopher Reger, MD. Disclosure: E.C. Marsiglia, None; C.D. Reger, None. Setting: Tertiary care hospital. Patient: A 40-year-old man with cadaveric renal transplant. Case Description: The patient had a cadaveric renal transplant performed after having end-stage renal disease from uncontrolled diabetes and hypertension. After 1 month of immunosuppressive therapy, he presented with mental status changes and falls. A noncontrast computed tomography of the brain was normal; however, his cerebrospinal fluid contained Cryptococcus neoformans and fluconazole was started. Assessment/Results: After his cryptococcal infection, the patient had functional and cognitive decline. He required comprehensive inpatient rehabilitation and had improved. 10 months post-transplant, he was readmitted for seizure disorder and found with imaging to have a superior right frontal lobe cystic lesion. He underwent a craniotomy and abscess removal. Pathology confirmed Nocardia farcinica infection and trimethoprim-sulfamethoxazole was started. Within 1 week, the patient had another seizure episode, and his antibiotic was changed for presumed resistance. Nonetheless, follow-up imaging noted a growing left parietal lesion requiring another craniotomy. Following each craniotomy, he participated in physical therapy and was able to be discharged with an improvement in his functional status. Discussion: Nocardiosis is a rare gram-positive aerobic bacterial opportunistic infection affecting 500 to 1000 patients per year in the United States. One third of infections affect the central nervous system, and few involve renal transplant recipients. Of the several known species, Farcinica is less often implicated but is more likely to show resistance to usual antibiotic regimens. Despite repeated infections and surgeries, this patient was able to maintain a high level of function because of rehabilitation. Conclusions: Functional decline may initially occur in the immunosuppressed patient with neurologic infection. However, this case demonstrates that with aggressive antibiotic therapy, surgery, and a comprehensive rehabilitation program, a satisfactory outcome was achieved in this complex and medically challenging patient.