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| Year : 1999 | Volume
: 47
| Issue : 3 | Page : 243-4 |
Nocardial abscess of spinal cord.
Mehta RS, Jain D, Chitnis DS
How to cite this article:
Mehta R S, Jain D, Chitnis D S. Nocardial abscess of spinal cord. Neurol India 1999;47:243 |
Nocardia infection of central nervous system (CNS) though uncommon, has been reported by various workers.[1],[2] It is usually disseminated from a primary infection in the lung. Primary infection of CNS without pulmonary involvement occurs only in 5-7% of patients. The site of infection is usually supratentorial and pathologically it consists of multi loculated thin walled abscess or abscesses. Rarely it involves cerebellum, spinal cord or meninges.
A 30 years female patient was admitted with history of fever, productive cough, painful swelling over left mastoid and left knee joint of seven days duration. Soon she developed weakness of both lower limbs with retention of urine and faeces. She had been having waxing and waning febrile illness and productive cough for the last one year. Her chest X-ray showed diffuse pulmonary lesions [Figure 1]. Chest CT also revealed bilateral diffuse parenchymal infiltration. Bronchoscopy and cytology were negative for malignancy. Sputum for AFB was negative. She had received antitubercular treatment along with other antibiotics, but did not improve. For the last six months she was on corticosteroids, with a diagnosis of allergic alveolitis, without any relief.
On examination the patient was febrile, debilitated, and anaemic. She had scar of previous pustular rash over face. There was abscess over left mastoid process. Her left knee was swollen, warm and tender. Chest examination revealed bilateral coarse crepitations. Neurologically she had paraparesis (power grade 1-2). The distal muscles were wasted and weaker than the proximal ones. Both knee and ankle jerks were absent. Plantar reflexes were not elicitable. Pin prick sensation was diminished over L4 to S3 dermatomes. Position and vibration sense was impaired in both the lower limbs. She had retention of urine with over flow. Plain X-rays of dorsolumbar region were normal. Limited MRI of dorsolumbar region revealed an intramedullary, round and coalescing lesion, hypointense on T1W image and hyperintense on T2W image, at D12 level, suggestive of an abscess [Figure 2]. Gadolinium enhancement could not be done. CSF examination showed protein of 45 mg%, sugar 39mg%, and 18 WBC/cumm, (70%L, 30%P). Smear was negative for AFB. Bacterial culture was sterile upto two weeks. Blood leucocyte count was 23,800/cumm with 82% polymorphs. Her haemoglobin was 8.5gm/dl. Liver and renal function test, rheumatoid factor, antinuclear antibodies, antibody for tuberculosis and HIV serology were negative. Pus from the abscess over left mastoid showed long filamentous organisms on gram staining, suggestive of nocardia. Auramine-O-staining and fluroscent microscopy showed weak acid fast filamentous forms. Culture after two weeks confirmed the growth of Nocardia. In view of multiple organ involvement and positive growth of Nocardia, she was treated with cotrimoxazole. Other antibiotics like amoxycillin + clauvulinic acid, amikacin and clarithromycin were added from time to time. She responded dramatically to treatment within 10 days. She became afebrile, chest symptoms resolved and arthritis improved. Within 20 days she was able to walk with support. Follow up after six months revealed that her chest had cleared clinically as well as radiologically. She was able to walk without any support and had better sphincter control. Power was grade IV proximally and grade III distally.
Nocardiosis occurs throughout the world and approximately 1000 cases of infection are diagnosed annually in U.S.A.[3] Nocardiosis belongs to group of actinomycetes which usually present as opportunistic infection in immunocompromised individual eg. AIDS, tuberculosis, organ transplant recipients, patients on immunosuppressant drugs, lymphoma and chronic alcoholics.[4] CNS is the most common site of the disseminated disease which is usually associated with high morbidity and mortality. In one series the mortality was 24% in operated patients and 30% in non operated patients. 22% were diagnosed at autopsy.[5] Since the advent of CT, the mortality has dropped by 50% because of early diagnosis and consequent early medical and surgical treatment. CT or MRI is mandatory for diagnosis of CNS nocardiosis. Multiloculated supratentorial abscess with ring enhancement is a typical picture. Subepndymal nodule, basal meningitis and hydrocephalous may occasionally be found. Imaging may also help therapeutically to drain the abscess stereotactically. The treatment of nocardiosis is also difficult. Prolonged course of antibiotics for 6-12 months is required. There is a tendency for relapse. Co-trimoxazole is the first drug of choice. Other drugs which can alternatively be used are minocyclin, amoxycillin and clauvulinic acid. Surgical drainage of CNS abscess is essential if abscess is large and superficial. Small deep seated abscess can be treated conservatively.
With increasing population of tuberculosis and AIDS it is likely to be more frequent in India as well. With high index of suspicion the diagnosis may not be difficult in an appropriate clinical setting. With an early diagnosis it could be a potentially curable infection.
| 1. | Beaman BL, Burnside J, Causey WA : Nocardial infection in United States. J Infect Dis 1976; 134 : 286-289.  |
| 2. | diagnosis, management and prognosis. J Neurol Neurosurg Psychiatry 1979; 2 : 1038-1045. |
| 3. | Greory A filice : Nocardiosis, In : Harrison's Principles of Medicine. Isselbacher K.J. et al (Eds) Thirteenth Edition. Mc Graw Hill, New York 1994 ; 13 : 696-697. |
| 4. | Simpson GL, Stinson EB, Egger MJ et al : Nocardial infection in immuno compromised host, a detailed study in a defined population. Rev Infect Dis 1981; 2 : 492-507. |
| 5. | Mamelak AN, Flaherty JF, Rosenblum ML : Nocardial brain abscess. Treatment strategies and factors influencing out come. Neurosurgery 1994; 35 : 622-631. |
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