Cerebral Nocardiosis Research Articles

Disseminated nocardiosis including cerebral nocardiosis caused by Nocardia farcinica: a case report

Background: As nocardiosis presents with nonspecific symptoms, its diagnosis is often difficult, resulting in high mortality. Here, we report a rare case of disseminated Nocardia farcinica infection that was successfully managed with a combination of antibiotic therapies. Case report: A 71-year-old man with idiopathic thrombocytopenia purpura presented with sudden-onset motor aphasia, motor weakness of the right limb, and fever. Brain magnetic resonance imaging revealed multiple scattered diffusion-restricted lesions. Multiple cutaneous and peritoneal nodules were also identified. We performed full-length 16S ribosomal ribonucleic acid (rRNA) sequencing and obtained basic local alignment search tool results against the National Center for Biotechnology Information 16S rRNA database, which showed the best match to be N. farcinica. After maintaining the antibiotics for approximately 56 days, the patient recovered full consciousness, and the motor weakness of the right limb improved.Conclusion: Timely diagnosis of disseminated or cerebral nocardiosis and treatment with appropriate antibiotics are crucial for a desirable clinical outcome.

Nocardia paucivorans Endophthalmitis and Cerebral Abscesses in an Immunocompetent Patient

Abstract Nocardia spp are an uncommon cause of central nervous system infections and particularly endophthalmitis. In this case report, we present the first documented case of endogenous Nocardia paucivorans endophthalmitis and subretinal abscesses. We also provide a brief summary of the literature regarding ocular and cerebral nocardiosis. Early diagnosis and management improve outcomes; hence, clinicians should be cognizant of Nocardia infection as a differential diagnosis in cases of cerebral abscess or endophthalmitis, including in the immunocompetent.

Lung and Cerebral Nocardiosis Caused by Nocardia elegans in a Lung Transplant Recipient: A Case Report and Literature Review.

Patients after lung transplantation are at risk for Nocardia infections. We herein report a case of lung and cerebral nocardiosis caused by Nocardia elegans, a rare species of Nocardia, in a lung transplant recipient. Antibiotic therapy, including sulfamethoxazole-trimethoprim (ST), and brain abscess drainage improved symptoms and imaging findings. A literature review of N. elegans infections showed that 12 of 14 cases (85.7%) were reported from East Asia, particularly Japan (9 cases, 64.2%). The lungs were the predominant site (12/14 cases, 85.7%), and most of the cases were susceptible to ST (9/10 cases, 90%).

Cerebral nocardiosis in ibrutinib-treated chronic lymphocytic leukaemia.

Cerebral nocardiosis in ibrutinib-treated chronic lymphocytic leukaemia.

A Fatal Case of Nocardia Bacteremia in a Lung Transplant Recipient

<h3>Introduction</h3> <i>Nocardia</i> bacteremia is an extremely rare disease. Although closely associated with immunocompromised states, only a few cases have been reported after lung transplant (LT). <h3>Case Report</h3> We present a case of <i>Nocardia</i> bacteremia in a 75-year-old man after bilateral LT (11/2017) for combined pulmonary fibrosis and emphysema. Nearing 3 years posttransplant, pulmonary function tests (PFTs) revealed an obstructive pattern with downtrending FEV₁ from baseline; work-up for acute cellular rejection, infection, and antibody-mediated rejection was unremarkable. Serial PFTs ultimately suggested CLAD-BOS phenotype, and he received photopheresis with some stabilization. However, over the next 2 months, he required 2 hospital admissions with need for high-dose intravenous steroids given hypercapnia in the setting of underlying rejection. At 38 months posttransplant, he developed lower extremity cellulitis and new-onset anorexia, generalized weakness, and rapid decline in mental status with need for a third hospitalization and mechanical ventilation with vasopressor support. Infectious work-up and empiric broad-spectrum antibiotic coverage were initiated. Within 12 hours, both blood cultures were positive for <i>Nocardia cyriacigeorgica</i> (Gram stain, <b>Figure A</b>). Meropenem and trimethoprim/sulfamethoxazole were substituted without clinical improvement over the next several days. Brain MRI ruled out cerebral nocardiosis; chest CT showed bibasilar consolidations with air space opacities. An echocardiogram estimated a left ventricular ejection fraction between 20-25% with severe diffuse hypokinesis, likely stress-induced cardiomyopathy, with no evidence of vegetations. Bronchoscopy revealed superinfection with pan-sensitive <i>Pseudomonas</i> spp, without isolation of <i>Nocardia</i> spp. The patient deteriorated and died 39 months after transplant. <h3>Summary</h3> <i>Nocardia</i> bacteremia, scarcely reported in LT recipients, portends a poor prognosis despite aggressive combination antimicrobial therapy.

Cerebral nocardiosis in a patient treated with pembrolizumab: a first case report

BackgroundCheckpoints inhibitors (CPIs) are increasingly used for the treatment of several malignancies. The most common side effects are Immune Related Adverse Events, while infectious complications are rare, especially cerebral nocardiosis.Case presentationHere, we report the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer, in the absence of any additional immunosuppressive therapy or risk factors for cerebral nocardiosis. The extended evaluation including a brain CT-scan did not reveal any lesion before pembrolizumab. Nevertheless, the 3-month delay between the start of Pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI. Unfortunately, the patient died during treatment for cerebral nocardiosis, while the lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab.ConclusionsThis case report emphasizes that clinicians should consider diagnoses other than metastasis in a patient with a brain mass and metastatic cancer treated with CPI, such as opportunistic infections or IRAE.

Isolated Cerebral Nocardiosis Otitidiscaviarum in a Child with relapsed B-Lymphoblastic Leukemia: Diagnostic and Therapeutic Challenges Including Relevant Review of Literature.

Isolated Cerebral Nocardiosis Otitidiscaviarum in a Child with relapsed B-Lymphoblastic Leukemia: Diagnostic and Therapeutic Challenges Including Relevant Review of Literature.

Brain Abscess Due To Asian Nocardia in a 63 Years-Old Patient with Adult Still´S Disease: A Rare Case Report and Literature Review

Cerebral nocardiosis is a rare and opportunistic pathology caused by a gram-positive, aerobic bacterium of the order of Actinomycetes called Nocardia spp. It appears in patients with immunodeficiencies affecting cellular immunity. Nocardia can affect an organ (lungs in 75% of cases) or manifest itself as a disseminated infection (central nervous system in 25% of cases). Here we present a rare case of 63-years-old patient immunocompromised by monoclonal biologic treatment for Adult-Onset Still disease (AOSD), who subsequently presents fever, signs of motor focality and resonance imaging findings which show supra and infratentorial lesions. The patient is managed in intensive therapy for sensory impairment, receiving standardized antibiotic scheme, getting through to complicated evolution. Cerebral nocardiosis is a rare infectious disease that requires an early diagnostic study and its respective treatment.

Intracranial Nocardiosis a Rare Condition: A Case Report

Cerebral Nocardiosis is a rare, challenging, opportunistic infectious disease of the central nervous system occurring in both immunocompetent and immunocompromised hosts. It often results in intraparenchymal abscess formation, which represents only 2% of all cerebral abscesses. The diagnosis of cerebral Nocardiosis is seldom based on imaging. Bacteriological diagnosis is often reached only after surgical excision of the abscess. We herewith reports 37 yr old patient with cerebellar abscess which grew nocardia.

ATYPICAL PRESENTATION OF BRAIN METASTASES IN PRIMARY LUNG ADENOCARCINOMA

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: This case describes an atypical presentation of primary lung adenocarcinoma with multiple brain metastases. It emphasizes the importance of tissue diagnosis to eliminate ambiguity and prevent a delay in appropriate treatment. CASE PRESENTATION: A 68 year-old female with past medical history significant for refractory subglottic stenosis with tracheostomy dependence secondary to prior motor vehicle accident requiring prolonged intubation, nicotine abuse (prior smoker; 112 pack years) presented with recurrent headaches,unintentional weight loss, worsening cough and progressive exertional dyspnea.Examination revealed some neurological deficits. Chest X-ray showed diffuse alveolar opacities in the left lung with lower lung predominance and minimal consolidation in the right lower lobe; these findings were new compared to prior X-ray from 9 months prior (Figure 1).Chest CT revealed diffuse interstitial and alveolar infiltrates,calcified granulomas and lymphangitic carcinomatosis pattern in the left-mid lung (Figure 2). MRI brain was suggestive of old right thalamus lacunar infarct and diffuse multiple ring-enhancing lesions without significant surrounding edema (Figure 3). The differentials of multi-focal infection versus metastatic disease were pursued. Pulmonology, ENT,Neurosurgery and Infectious Disease services were consulted for their input. CSF studies were not consistent with infection or malignancy.Exhaustive serological work up was negative for infection but sputum samples revealed non-tuberculous mycobacterium (rapid grower) for which therapy was initiated. In view of the inconsistent imaging and microbiology findings, tissue biopsy was deemed necessary. As bronchoscopic biopsy would pose a technical difficult given significant tracheal stenosis, brain biopsy was pursued. Biopsy was obtained from the frontal lobe following a stealth-guided craniotomy. Tissue samples were negative for infectious etiology. Pathology was consistent with primary lung adenocarcinoma with molecular profiling demonstrating aneuploidy for ALK and ROS genes. Patient was discharged with medical oncology and radiation oncology follow-up outpatient to initiate treatment. DISCUSSION: This case is unique because of its microbiological and radiological findings. The patient’s chest imaging from approximately nine months prior was completely unremarkable. In addition to the inconsistent timeline, there was no involvement of the right lung on imaging to support the diagnosis of distant metastatic spread; thus making infectious etiology more likely. CONCLUSIONS: Although non-invasive diagnosis of brain metastases is preferred in the majority of cases, brain biopsy may be necessary when imaging is ambiguous. Reference #1: Mota, P.C., Reis, C., Pires, N.F. et al. Lung cancer: atypical brain metastases mimicking neurocysticercosis. Int J Clin Oncol, 16, 746–750 (2011). Reference #2: Choi, H., Choi, S. Multiple Cystic Brain Metastases from Adenocarcinoma Mimicking Cysticercosis. Clin Neuroradiol, 22, 105–107 (2012). Reference #3: Voide, Cathy et al. Cerebral Nocardiosis Mimicking Multiple Brain Metastases in a Patient with Locally Advanced Non–Small-Cell Lung Cancer. Journal of Thoracic Oncology, 9(3), e24 - e26. DISCLOSURES: No relevant relationships by Olaedo Abana, source=Web Response Site Investigator for EMPROVE relationship with Olympus-Spiration Please note: $1001 - $5000 Added 06/15/2020 by Robert Holladay, source=Web Response, value=Grant/Research Support Site Investigator for DAS 181 relationship with Ansun pharmaceutical Please note: $1001 - $5000 Added 06/15/2020 by Robert Holladay, source=Web Response, value=Grant/Research Support No relevant relationships by Louisiana University, source=Web Response

Nocardiosis Associated with Primary Immunodeficiencies (Nocar-DIP): an International Retrospective Study and Literature Review.

Nocardiosis is a life-threatening infectious disease. We aimed at describing nocardiosis in patients with primary immunodeficiency diseases (PID). This international retrospective cohort included patients with PID and nocardiosis diagnosed and/or published from Jan 1, 2000, to Dec 31, 2016. To identify nocardiosis cases, we analyzed PID databases from the French National Reference Center for PID (Paris, France) and the National Institute of Health (NIH, United States of America) and we performed a literature review on PubMed. Forty-nine cases of nocardiosis associated with PID were included: median age at diagnosis of nocardiosis was 19 (0-56)years and most cases were observed among chronic granulomatous disease (CGD) patients (87.8%). Median time from symptoms to diagnosis of Nocardia infection was 20 (2-257)days. Most frequent clinical nocardiosis presentation was pneumonia (86.7%). Twelve-month mortality rate was 4.2%, and 11.9% of patients experienced a possible recurrence of infection. Nocardiosis more frequently led to the diagnosis of PID among non-CGD patients than in CGD patients. Non-CGD patients experienced more cerebral nocardiosis and more disseminated infections, but mortality and recurrence rates were similar. Highest incidences of nocardiosis among PID cohorts were observed among CGD patients (0.0057 and 0.0044 cases/patient-year in the USA and in France, respectively), followed by IL-12p40 deficiency. Among 49 cases of nocardiosis associated with PID, most patients had CGD and lung involvement. Both mortality and recurrence rates were low.

P1771NOCARDIOSIS IN RENAL TRANSPLANT RECIPIENTS- TEN YEARS OF SINGLE CENTER EXPERIENCE

Abstract Background and Aims Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. This study aimed to retrospectively review the clinical course and outcome of nocardiosis in renal transplant recipients at our center Method Data was obtained from hospital records retrospectively. Sixteen cases of nocardiosis were identified in a series of more than 1800 consecutive renal transplants performed at Sir Ganga Ram Hospital in the last decade from the year 2010 to 2019. Results Thirteen out of Sixteen patients(81.25%) had developed nocardiosis within a 1-year post-renal transplant. The diabetic population constituted 31.3%. CMV disease was present in 25% of patients six months prior to the diagnosis of Nocardiosis.56.3% of patients were on Trimethoprim-sulfamethoxazole prophylaxis while they were diagnosed with nocardiosis. Pleuropulmonary nocardiosis was the most common form of infection(68.75%). Primary cutaneous nocardiosis was identified in one patient(6.25%). cerebral nocardiosis and disseminated nocardiosis was diagnosed in two patients each(12.5%).In the last 3 years with the introduction of MALDI-TOF led to the identification of the subspecies of Nocardia which was not possible earlier. In the last 3 years, 6 patients were diagnosed with nocardiosis, in which 4 were infected with Nocardia farcinica, one patient with Nocardia Asiatica and one with Nocardia cyrigeorgica. Nocardia farcinica was resistant to cotrimoxazole, which used to be first-line therapy against Nocardiosis before subspecies identification and sensitivity testing. With the help of proper identification of subspecies by MALDI-TOF and antibiotic susceptibility by E-testing, 5 out of 6 patients could be treated while earlier 6 out of 10 patients could be treated. Conclusion Nocardiosis is a rare, difficult-to-diagnose-and-treat infection following kidney transplantation. Trimethoprim-sulfamethoxazole prophylaxis was not effective in the prevention of disease. The Subspecies identification and modification of the plan of management according to antibiotic sensitivity results in improved outcomes.

1416. Nocardia beijingensis: A Rare and Unusual Cause of Intracranial Abscess

BackgroundNocardia species are thin, aerobic, filamentous, gram-positive bacilli that are ubiquitous in soil worldwide. Nocardia infections are divided into three main categories: pulmonary nocardiosis, disseminated nocardiosis, and cutaneous nocardiosis.MethodsWe present a case of cerebral nocardiosis in an immunocompetent patient caused by Nocardia beijingensis (NB).ResultsA 60-year-old Caucasian lady from Florida with type 2 diabetes mellitus, hypertension, hyperlipidemia, presented to the emergency room with complaints of altered mentation. Per husband, she was having episodes of emesis and diarrhea 3 days prior to admission that resolved however, her mentation significantly deteriorated to where she was unable to perform simple chores around the house. Pertinently she had resection of lung mass 2 months prior to admission which found to be benign. Vital sign at admission was stable and on examination, the patient was alert and oriented, however, lethargic appearing. Neurological examination was pertinent for expressive aphasia; however, cranial nerves II-XII were grossly intact. The patient was also found to have a 3 cm by 4 cm, tender, cystic lesion on the left-sided occipital scalp. The remainder of the physical examination was unremarkable. Admission laboratories were remarkable for leukocytosis and hyperglycemia. MRI of the brain was completed that showed multiple areas of vasogenic edema and multiple nodules with the largest being 1.8 cm suggestive of abscesses. She was started empirically on vancomycin, ceftriaxone, metronidazole, and ampicillin. Cerebral spinal fluid showed neutrophilic pleocytosis, low glucose, and high protein. Initial cultures including CSF were negative. Left-sided occipital scalp lesion was excised and sent for pathology and culture. Initial cultures showed gram-positive bacilli, so antibiotics were de-escalated to sulfamethoxazole/trimethoprim and ceftriaxone. Repeat imaging showed improving abscess, and final cultures resulted in NB.ConclusionNB is believed to have originated in Southeast Asia. NB has been associated mainly with infections in immunocompromised. In the United States, the two only other cases of NB described in immunocompetent hosts were interestingly from Florida as well. Disclosures All authors: No reported disclosures.

2384 Unusual Cause of Encephalopathy in an Immediate Post Transplant Patient

INTRODUCTION: Brain abscesses are a rare complication post liver transplantation. They can present as a wide array of symptoms that can include fever, headache, focal deficits, or altered mental status. Immunosuppression makes transplant patients more susceptible to a wide array of microorganisms. We present a case of Nocardia farsinica brain abscess in a patient 4 months after liver transplantation. CASE DESCRIPTION/METHODS: A 76-year-old male with known cirrhosis from fatty liver disease, and recent liver transplant presenting with acute encephalopathy. Four months earlier, the patient received a liver transplant secondary to Nash cirrhosis. His post-operative course showed no infectious complications. He did have issues with mobility and was placed in a rehab facility. He was on tacrolimus as well as azathioprine for immunosuppression. He had hyperkalemia at rehab and his trimethoprim–sulfamethoxazole was held. The patient's family brought him to the hospital for changes in mental status. The patient met sepsis criteria on admission. CT of the head showed multifocal hypoattenuation lesions. MRI with contrast was obtained which showed multiple peripherally enhancing lesions. On peripheral history he had fallen at rehab and developed a hematoma of his thigh. The fluid collection on his thigh which was aspirated. Culture results were concerning for Nocardia. Patient was presumed to have cerebral nocardiosis and was started on imipenem and trimethoprim–sulfamethoxazole. The culture confirmed Nocardia farcinica. During his hospital stay, patient's mental status gradually improved. He was discharged on imipenem and Bactrim. Repeat MRI one year later showed complete resolution of lesions. DISCUSSION: Nocardia intracranial abscesses represent a rare complication post liver transplantation; although, infection is a common cause of mortality following liver transplantation. Opportunistic infection prophylaxis is vital and his lapse was likely cause of this infection. Patients that present with fever require expansive evaluation for the common and uncommon infectious causes. Any transplant patient with new or changing headache or altered mental status require imaging of the CNS as well as a lumbar puncture. Imaging, physical exam, cultures and serologies can then further delineate the cause. Brain abscesses have high morbidity and mortality; therefore, prompt diagnosis and treatment is vital.

Cerebral Nocardiosis: A Rare Cause of Hemiplegia in the Acute Medicine Unit

Nocardiosis, a rare infection occurring mostly in immunosuppressed patients can present with neurological complications including cerebral abscess formation, and is associated with high morbidity and mortality. We describe the case of a 54-year-old immunocompetent man with cerebral nocardiosis, who presented with sudden onset hemiparesis in an acute medicine unit. He required three craniotomies with excision, following failure to respond to antimicrobial therapy, with subsequent clinical improvement and radiological resolution of multiple cerebral abscesses. Challenges in diagnosis and management of hemiparesis in the acute medical unit are discussed. Successful management of cerebral nocardiosis require early communication with a neurosurgical unit, neuropathology and microbiology services to optimise management with targeted antimicrobial therapy.

Cerebral Nocardiosis in a Patient With Rheumatoid Arthritis Under Treatment With Tocilizumab

The use of biological therapy has revolutionized the treatment of various autoimmune diseases. Tocilizumab (TCZ) is a recombinant humanized antiinterleukin-6 (IL-6) receptor monoclonal antibody approved for the treatment of patients with rheumatoid arthritis, as monotherapy or in combination with other disease-modifying anti-rheumatic drugs (DMARDs). Clinical and post-marketing surveillance studies of TCZ indicate that infections are the most frequent adverse events. Most of the serious infections described are bacterial and viral, with no uncommon pathogens. The authors report a case of a patient with destructive rheumatoid arthritis under TCZ that presented with neurological symptoms and a right cerebellar lesion with marked diffusion restriction suggestive of cerebellar abscess. The microbiologic studies from aspirative cerebral biopsy revealed Nocardia farcinica . With adequate antibiotics, the patient evolved with resolution of all symptoms and brain abscess at 5 months of follow-up. According to published reports, this is the first case of nocardial infection in patients under TCZ. The case highlights the importance of being aware of risk infection in these patients and need of an early diagnosis allowing a prompt treatment. J Med Cases. 2018;9(2):68-72 doi: https://doi.org/10.14740/jmc2995w

Cerebral Nocardiosis in a Patient With Rheumatoid Arthritis Under Treatment With Tocilizumab

Cerebral Nocardiosis in a Patient With Rheumatoid Arthritis Under Treatment With Tocilizumab

Nocardiose : analyse rétrospective d’une série de 19 cas

IntroductionNocardiosis are uncommon. The diagnosis may be difficult, with significant morbidity and mortality, often occurring on frail patients. Few data are available in France. MethodsA retrospective single center study was conducted from 2002 to 2014 and included all patients with at least one positive microbiological sample for Nocardia with a follow-up in our hospital. ResultsNineteen patients, including 15 men, were included with a mean age of 58 years (25–85). Seventeen had a risk factor (lung diseases [13], corticosteroids [12], solid neoplasia [2], HIV infection [2], diabetes mellitus [3], kidney transplant [2], lymphopenia [1]). Infections’ locations were: pulmonary (12), brain (3), skin (2), lymph node (1) and corneal (1). The slow growth leads to a median of 35 days for a positive result (3–95). Nine species were identified. Fifteen patients (79%) received one or more lines of antibiotics including: cotrimoxazole (9), amoxicillin (7) cefotaxime/ceftriaxone (7) imipenem (3), or amikacin (3). The average duration of antibiotic therapy was 207 days. Four patients did not receive antibiotics due to a late result or a bacterial co-infection masking nocardiosis. Five patients died (26%) including 2 with cerebral nocardiosis. Six patients were cured, 4 suffered a relapse, 4 had an unknown evolution, and 1 was still treated. ConclusionOur study shows that nocardiosis is a disease difficult to treat. A better understanding of this type of infection is necessary.

An Unusual Case of Cerebral Nocardiosis Masquerading as Tuberculosis

An Unusual Case of Cerebral Nocardiosis Masquerading as Tuberculosis

Clinical Pathway in the Treatment of Nocardial Brain Abscesses following Systemic Infections.

Nocardial infections are commonly encountered in patients with immunocompromised states. Cerebral nocardiosis is an uncommon clinical entity, representing only 2% of all cerebral abscesses. It has a higher mortality rate, especially for multiple cerebral lesions in immunocompromised hosts following systemic infections. However, an optimal treatment policy to deal with these immunocompromised patients in Asia is still lacking. We retrospectively reviewed the subjects with nocardial brain abscesses from 2001 to 2011 at our medical center. All of them had multiple brain abscesses, underlying with immunocompromised state following systemic infections. All cases were under steroid control due to their comorbidities for more than six months. The comorbidities and misdiagnosis often lead to poor prognosis. The change in the environments of the microorganisms caused by immunosuppressive agents and multiple antibiotic uses may play an important role in this critical disorder. Aggressive craniotomy should be performed in time to avoid grievous neurological outcomes. Our conclusion is that early diagnosis and appropriate antibiotic uses should be implemented promptly, and aggressive craniotomy should be performed for nocardial brain abscesses in subjects with systemic infections under an immunocompromised status.