Primary Nocardia farcinica Brain Abscess With Secondary Relapsing Meningitis in an Immunocompromised Patient

Abstract

Nocardiosis is an opportunistic infection primarily affecting immunocompromised patients. Central nervous system (CNS) involvement in the form of cerebral abscesses may be a complication of nocardia infection. Nocardia farcinica, in particular, is believed to disseminate the CNS more often than other nocardia species, being associated with antibiotic resistance and therefore higher mortality. We describe the first case of a patient with relapsing meningitis caused by N. farcinica. A 61-year-old Caucasian man was admitted for evaluation of fever, headache and confusion. Magnetic resonance imaging of the brain revealed cerebral abscesses and examination of the cerebrospinal fluid (CSF), polymorphonuclear count, elevated protein and hypoglycorrhachia. CSF cultures were negative, while multiplex polymerase chain reaction showed Staphylococcus aureus. The patient received vancomycin/meropenem and later, because he was still febrile, with symptoms from the CNS, linezolid/meropenem, in which he responded well. During the following months, he had to discontinue linezolid because of myelosuppression with subsequent relapses of meningitis. In such a relapse, the patient was admitted for reevaluation. CNS cultures grew N. farcinica, susceptible to linezolid, trimethoprim/sulfamethoxazol and ceftriaxone. He was discharged on trimethoprim/sulfamethoxazole for 12 months. This is the first reported case of relapsing meningitis caused by N. farcinica. It highlights, on the one hand, the importance of the prolonged treatment in relapse's prevention and on the other, the limited value of linezolid as prolonged treatment due to its long-term toxicities.

Nocardia farcinica pituitary abscess in an immunocompetent patient: illustrative case

“…7,8 Rare N. farcinica CNS abscesses have been reported, almost exclusively among immunocompromised or elderly patients. 5,[9][10][11] No prior case of Nocardia pituitary abscesses has been documented, neither in an immunocompromised nor an immunocompetent patient. We present the index case of N. farcinica pituitary abscess, which arose in a young, healthy host and was subject to a challenging course before the correct diagnosis was established and curative treatment was initiated.…”