Nocardial brain abscess: an unusual cause of acute confusion.
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A 19-years-old male was admitted for left bilobar pneumonia. All microbiologic studies in blood and in several samples obtained by bronchoscopy were negative. The patient worsened progressively despite antibiotherapy of a wide spectrum. A fine needle transparietal puncture was performed. The cultures of the sample were positive for Nocardia asteroides, a positive catalase germ. Immunologic studies initiated after this time showed negative tetrazolium nitroblue test, the results of which led to the diagnosis of chronic granulomatous disease. This disease is very infrequent and the polymorphonuclear leukocytes are genetically incapable of producing peroxides whose absence impedes lysis of the positive phagocytic catalase germs with which a histologic reaction is produced in the form of granulomas from which the name of the disease is derived.
We report a case of nocardiosis in a 42, years male with common variable immunodeficiency syndrome (CVID). He presented with arthritis, subcutaneous abscess and pleural effusion. Diagnosis of CVID was made during this presentation. Serum IgG, IgA and IgM levels were markedly decreased. Nocardia asteroides was cultured from pleural fluid. He was successfully treated with intravenous immunoglobulin and cotrimoxazole.
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A 65-year-old man with 9 months of radicular lower back pain was admitted for treatment of presumed malignancy of the lumbar spine. Lumbar radiographs showed destruction of the L4-L5 endplates and obliteration of the disc space, which was more compatible with an infectious process. After 2 different closed biopsy specimens failed to reveal an etiologic organism, N. asteroides was cultured from an open biopsy sample of the affected vertebrae. This and 8 other cases in the English literature of vertebral osteomyelitis caused by N. asteroides are reviewed.
A 44-year-old renal transplant recipient, developed a systemic nocardiosis with cerebral abscess and without pulmonary involvement. Immunosuppressive therapy was discontinued and combination of surgical drainage procedures and prolonged chemotherapy with TMP/SMX were successful. His renal function remained stable and he has had no recurrence of nocardiosis.
A total of 209 cases of pulmonary tuberculosis were screened for the presence of Nocardia in their sputa. In 2.9 per cent of the cases Nocardia asteroides was isolated. The increasing importance of this microorganism has been discussed in the light of other reports from India.
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Pericardial nocardiosis is extremely rare, but may affect especially immunocompromised hosts. We describe the first reported case of purulent pericarditis with cardiac tamponade as the initial presentation of systemic nocardiosis in a patient with mixed connective tissue disease. Our case emphasizes the importance of identifying infectious causes of pericarditis in patients with connective tissue diseases. Longterm survival was achieved with a combined medical and surgical approach.
A case of subcutaneous abscess caused by Nocardia asteroides in an immunocompromised patient is described. A specific antibiotic therapy was successful. Details of the isolation procedures, clinical significance and epidemiological aspects related to the pathogen strain are reported.