Nocardia brain abscesses Marija Kusulja MD Vladimir Krajinović, MD, PhD University Hospital for Infectious Diseases „Dr Fran Mihaljevic”, Mirogojska cesta 8, Zagreb, Croatia

Medical history Present illnes: A 71-year old male patient presented to University Hospital Centre with twitching of left arm and left side of face lasting 30 minutes, and terminating on diazepam 10 mg intravenously On further history, he is noted to have had pins and needles in his left arm for the past 2 months Previous medical history: nephrotic syndrome caused by minimal-change disease (treatment with prednisolone for 11 years) iatrogenic diabetes mellitus type 2

Figure 1 3 months earlier he underwent surgical treatment for right knee swelling, preoperative work-up revealed lung infiltrates (Figure 1) and blood cultures grew Nocardia spp., so he received amikacin, TMP/SMX and ceftriaxone for systemic nocardiosis for 5 weeks, continuing TMP/SMX after discharge

Figure 2: Brain MSCT on current admission On current admission the patient underwent brain MSCT because of neurological symptoms. It revealed billateral temporoparietal zones of edema with three opacified oval secundary changes, 12-23 mm in diameter He was then transferred to the University Hospital for Infectious Diseases Zagreb, Croatia

Figure 3: Brain MR on current admission Multiple brain absesses bilaterally parietally, two in the right hemisphere, one in the left, with extensive perifocal edema and compression of occipital horn of the right lateral ventricle, without herniation

Course of treatment Blood cultures grew: Nocardia cyriacigeorgica MIC tetracyclines 0.25 μg/ml, ciprofloxacine R, co-amoxiclav I Treament with: TMP/SMX Amikacin Imipenem Neurosurgeon consulted after 6 weeks of antibicrobial treatment: No indication for surgical intervention Peroral therapy on discharge: TMP/SMX, doxycycline

Figure 4: Brain MR after 7 months of treatment Brain MR after 7 months of treatment showed significant regression of the size of all abscesses, as well as perifocal edema The patient was subjectivelly well, with occassional frontal headaches Therapy is planned to continue for a total of 2 years Figure 4

Nocardiosis A rare opportunistic infection (although 1/3 of patients are immunocompetent) with gram-positive aerobic rods of Nocardia genus It can cause localized or disseminated infection in any organ It is always a pathological finding in any sample of human body It can progress despite adequate therapy, and recur years after successful therapy Treament foundation: TMP/SMX + combination therapy in severe disease (variable antibiotic susceptibility) Duration of treatment: 3 months in isolated cutaneous infection to 12 months or longer for CNS involvement or immunocompromised host Surgery in case of CNS abscess not responding to antibiotic therapy, empyema, pulmonary nocardiosis with pericarditis