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

2. 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

3. 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

4. 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, mm in diameter
He was then transferred to the University Hospital for Infectious Diseases Zagreb, Croatia

5. 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

6. 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

7. 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

8. 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