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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 1 | Page : 105-107
Multiple nocardial cerebral abscesses in a patient with pulmonary aspergillosis
Prasad Krishnan, Rohit Mishra, Rajaraman Kartikueyan, Eswara Rao Thamatapu
Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India
|Date of Submission||22-Oct-2013|
|Date of Decision||29-Dec-2013|
|Date of Acceptance||29-Jan-2014|
|Date of Web Publication||7-Mar-2014|
Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnan P, Mishra R, Kartikueyan R, Thamatapu ER. Multiple nocardial cerebral abscesses in a patient with pulmonary aspergillosis. Neurol India 2014;62:105-7
A 73-year-old female presented with holocranial headache, fever and gradually progressive right sided weakness, gait ataxia and slurring of speech of 1 month duration. She had a history of recurrent bronchopleural fistula and underwent left minithoracotomy and pleurodesis 3 months before onset of neurological symptoms. She was a known patient of interstitial lung disease for which she was on oral steroids and had been previously treated for aspergillosis of lung with voriconazole for 4 weeks following which there was improvement of haziness on chest X-ray and complaints of fever and respiratory difficulty subsided. Magnetic resonance imaging scan of brain showed multiple intracranial cystic ring enhancing lesions in bilateral cerebral hemispheres, midbrain and cerebellar vermis [Figure 1]. She was empirically put on both antifungal agents and also antituberculous drugs. Computed tomography (CT) scan done 1 month later showed increase in size of the lesions [Figure 2]. Examination showed bilateral papilledema and right hemiparesis. She underwent left parietal awake craniotomy and drainage of abscess, containing thick yellow pus, and excision of surrounding tough and avascular wall. The capsule wall showed non-specific granulation and a mixture of neutrophils, lymphocytes and plasma cells. No granulomas or giant cells were seen. Nocardia was not confirmed on histology but culture of the pus grew Nocardia sp. Antifungal agents and antituberculous drugs were stopped and she was put on trimethoprim and sulphamethoxazole (160 mg and 800 mg) at a dosage of 2 tablets thrice daily for 1 year. Repeat CT scan showed complete resolution of all the lesions [Figure 3]. At the end of 1 year the patient had no respiratory complaints and was not investigated for residual lung disease.
|Figure 1: Contrast enhanced magnetic resonance imaging scan showing lesion in vermis, midbrain, occipital region and left insular cortex|
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|Figure 2: Contrast enhanced computed tomography scan showing lesion in vermis, conglomerate lesions in the midbrain and left parietal surfacing lesion. The lesions have a hypodense center and an enhancing periphery|
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|Figure 3: Contrast enhanced computed tomography scan showing no residual lesion|
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Nocardia an opportunistic gram positive aerobic bacterium first described by Edmond Nocard in 1888,  is found in soil and water.  The organism enters the body by inhalation or cutaneous inoculation  primarily causing pneumonia.  Central nervous system (CNS) involvement occurs by hematogenous dissemination from pulmonary nocardiosis. ,, It has a tropism for the CNS.  Though cerebral nocardial abscesses (CNA) account for only 2% of all intracranial abscesses, , they occur in 44% of patients with systemic nocardiosis.  Most commonly the infection occurs in immune-compromised individuals, , however its infection has also been reported in immunocompetent individuals. ,,, The incidence of CNA is increasing due to improved survival of patients with immune suppressed states, increase in incidence of acquired immunodeficiency syndrome and improved diagnostic techniques.  However, due to its rarity  it is seldom kept as a primary diagnosis and is often mistaken for malignancy ,,, as occurred in our patient too.
In some studies CNA was predominantly supratentorial (57%),  however in other studies the hallmark of nocardial abscess was occurrence in the cerebellum and deep nuclear structures of the cerebral hemispheres.  Our patient in addition to supratentorial cortical involvement, also had midbrain and vermian abscesses. Of interest is the association the disease seems to have with concomitant lung disease. ,, As 40% of CNA occur with no evidence of other organ involvement, primary lung infection may be subclinical.  Some authors hold that lung nodules on imaging in a setting of CNA represent pulmonary involvement. 
Joung et al.  have described an immunocompetent patient who had concurrent pulmonary aspergillosis and CNA. They also reported the co-existence of both pathologies in the immunocompromised. However in their case, the diagnosis of cerebral nocardiosis preceded that of pulmonary aspergillosis. In our patient there was a preceding history of pulmonary aspergillosis that led to initiation of empirical antifungal treatment. At the time of diagnosis of pulmonary aspergillosis, the possibility of pulmonary nocardiosis was not kept in mind it would thus not be possible to say if the brain abscesses in this patient were a delayed manifestation of systemic nocardial infection. She was on steroids for interstitial lung disease but this was tapered off as soon as the diagnosis of nocardial cerebral abscess was established. The standard regime  of trimethoprim and sulfamethoxazole was given to our patient with gratifying results.
CNA have high morbidity and mortality (30%) , as compared to 10% for other abscesses.  This is said to be highest among all cerebral abscesses.  Mortality is greater in immunocompromised (55%) as compared to immunocompetent (20%) patients.  Hence early aggressive treatment needs to be instituted and the possibility of nocardiosis should be considered in all brain abscesses. Serological tests are not useful  and only cultures can establish a diagnosis of nocardial abscess. Antimicrobial drug sensitivity testing is not standardized  and empirical sulfonamides are the backbone of treatment.  Various other antibiotics such as linezolid, amoxicillin/clavulanate, imipenem, minocycline etc., have also been described.  Due to high relapse rate,  prolonged therapy (several months) ,, is advocated.
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[Figure 1], [Figure 2], [Figure 3]