We describe a case of 91-year-old male with astrocytoma who developed meningitis caused by Nocardia farcinica. He had a past medical history of anaplastic astrocytoma grade III. Endocranial computed tomography (CT) scan revealed mass lesion in the left occipital region associated with perilesional edema, without evidence of midline shift issue. The analyses of cerebrospinal fluid (CSF) revealed neutrophilic pleocytosis, hyperproteinorrachia and hypoglycorrhachia. Combined antimicrobial therapy was initiated (vancomycin, meropenem, acyclovir). CSF culture revealed Nocardia farcinica. Susceptibility testing revealed intermediate sensitivity to meropenem and antibiotic treatment was switched to trimethoprim-sulfamethoxazole and imipenem. After 7 days of treatment the patient developed progressive dyspnea. The chest CT scan revealed bilateral pleural effusion and alveolar infiltrate mostly in the right lobe. Ceftriaxone was added to the therapy, but the outcome was lethal. Nocardia spp. should be considered as differential diagnosis in the patients with brain tumor or meningitis in the setting of immune suppression and corticosteroid use. CSF cultures should be incubated longer with aim to allow fastidious organisms to grow, such as Nocardia spp.
Introduction: Nocardia species are described as opportunistic pathogens that mainly cause pulmonary nocardiosis in immunocompromised individuals, particularly in patients with acquired immune deficiency syndrome (AIDS), intravenous drug abusers, strongly burned victims, the Cushing syndrome, the ones underlying transplantation, and prolonged use of corticosteroids. Case Presentation: The current paper reported a case of disseminated nocardiosis in a 28-year-old Iranian male who had type 2 diabetes mellitus with prolonged use of corticosteroid for the last 5 years. He was admitted to the department of infectious diseases at Shahid Beheshti hospital, Tehran, Iran, following a complaint of pneumonia (chest pain) and presented a subcutaneous purple nodule on the left thigh without pain. Direct microscopic examination revealed numerous filamentous branching and rod-shaped bacilli. The tentative diagnosis of chronic inflammation with nocardiosis was made. In addition, tiny, chalky white and irregular colonies emitting an earthy odor appeared on blood and chocolate agar and were identified as Nocardia brasiliensis by sequencing of 16S rRNA gene as a valuable method to identify clinical isolates. Combination therapy was performed by entire surgical excisions and intravenous TMP-SMX (160/800 mg/bid; IV) and meropenem 1g/tid. The patient's condition improved after 8 days and he was discharged. Conclusions: Combination therapy with surgical excision has a synergistic effect and appears to be the best treatment for extended lesions. However, new potent antibacterial drugs may help to improve the management of such infections when there are sufficient data on their in vitro activity.
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