Nocardiosis of the Central Nervous System

Abstract

Central nervous system (CNS) nocardiosis is a rare disease entity caused by the filamentous bacteria Nocardia species. We present a case series of 5 patients from our hospital and a review of the cases of CNS nocardiosis reported in the literature from January 2000 to December 2011. Our results indicate that CNS nocardiosis can occur in both immunocompromised and immunocompetent individuals and can be the result of prior pulmonary infection or can exist on its own. The most common predisposing factors are corticosteroid use (54% of patients) and organ transplantation (25%). Presentation of the disease is widely variable, and available diagnostic tests are far from perfect, often leading to delayed detection and initiation of treatment. The optimal therapeutic approach is still undetermined and depends on speciation, but lower mortality and relapse rates have been reported with a combination of targeted antimicrobial treatment including trimethoprim/sulfomethoxazole (TMP-SMX) for more than 6 months and neurosurgical intervention.

Nocardiosis: An Emerging Infectious Actinomycetic Disease of Humans and Animals

“…Recently, Rodriguez-Nava and others reported Nocardia mexicana, a new pathogen from human ISSN: 2474-4530 mycetoma [6]. A number of risk factors such as organ transplant, HIV/AIDS, lymph reticular malignancy, tuberculosis, alcoholism, diabetes mellitus, cirrhosis, sarcoidosis, renal failure, and long term corticosteroid can predispose the individual to nocardial infections [2,3,30,14]. Though Nocardia may act as primary and opportunistic pathogen, the maximum cases are recorded in immunologically compromised patients [3,14].…”

“…Computerized tomography (CT) and magnetic resonance imaging (MRI) are useful to reveal the lesions in the organs [3]. Nocardia species can be isolated from pus, sputum, brocho-alveolar lavage, pleural fluid, cerebrospinal fluid, blood, peritoneal fluid, synovial fluid, empyema fluid, milk, corneal tissue, lymph nodes, lung, brain on several nutrient media such as brain heart infusion agar, blood agar, Sabouraud dextrose agar, and Lowenstein Jensen agar [3,10,24]. On Sabouraud dextrose agar dry, irregular, whitish to orange coloured colonies are noticed.…”

“…Acute form of disease is particularly observed in compromised host. The clinical signs include fever, cough, sputum, dyspnoea, pleuritic chest pain, malaise, night sweats, nausea, vomiting, weight loss, haemoptysis, pneumonia, empyema, pericarditis, synovitis, peritonitis, encephalitis, severe headache, seizures, ataxia, altered mental status, meningism, polyuria, urinary incontinence, lymphadenitis, lymphangitis, endophthalmitis, and corneal ulcer [1,3,7,28]. About one third of patients with progressive pulmonary disease develop metastatic brain abscesses.…”

“…As signs and symptoms are not specific, diagnosis can be challenging. A number of chemotherapeutic agents are available; however, trimethoprimsulphamethazole is the drug of choice for central nervous system (CNS) nocardiosis due to its good penetration into brain [3]. The early disease may respond to prolonged treatment with antimicrobials, and the duration of therapy is uncertain.…”

“…It is primarily an opportunistic infection but can also cause life threatening disease in immunocompetent individuals [2,3]. It is an emerging infectious disease, which has been reported from many countries of the world including India [4][5][6][7].…”