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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 1 | Page : 92-93 |
Nocardial abscesses occurring in both sides of brain in an immunodeficient individual
Yunyan Zhang1, Bing Guo1, Pinghua Qu1, Wei Ran2
1 Department of Craniomaxillofacial Surgery, The First Affiliated Hospital, Sun Yat sen University, Guangzhou, Guangdong Province, China
2 Department of Laboratory Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, 111 Dade Road Guangzhou, Guangdong Province, China
| Date of Submission | 26-Nov-2012 |
| Date of Decision | 02-Dec-2012 |
| Date of Acceptance | 20-Jan-2013 |
| Date of Web Publication | 4-Mar-2013 |
Correspondence Address:
Wei Ran
Department of Laboratory Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, 111 Dade Road Guangzhou, Guangdong Province
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.108039
How to cite this article:
Zhang Y, Guo B, Qu P, Ran W. Nocardial abscesses occurring in both sides of brain in an immunodeficient individual. Neurol India 2013;61:92-3 |
Sir,
Nocardiosis is an unusual opportunistic infection in humans caused by Nocardiae which are found worldwide in soil, sand, and house dust. [1] Nocardial brain abscess is one of the common presentations in nocardiosis, but bilateral nocardial brain abscesses are rare. The clinical condition deteriorates rapidly with a mortality as high as 66%. [2] Total excision or aspiration is necessary in most cases. [3] Here we report a patient with bilateral nocardial brain abscesses, who was successfully treated with conservative therapy.
A 66-year-old woman presented with slowly progressive headaches, dizziness, and fever of 20 days duration. She is a known case of pure red cell aplasia and diabetes mellitus. Examination showed neck rigidity and a round tender mass of about 3 cm 2 near fibular region of the left leg. Cranial computed tomography (CT) showed multiple hypodense lesions in the right occipital lobe and left cerebellum with faint ring enhancement after contrast administration [Figure 1]. She was started empirically on intravenous ceftriaxone and oral fluconazole. However, her condition got worse on day 3 with the level of consciousness rapidly declining and the left leg swelling formed an abscess. Patient's relatives declined consent for cranial surgery. Aspiration from the left leg swelling showed thin, branching Gram-positive rods suggestive of infection by Nocardia species. Then she was started on four tablets of sulfamethoxazole (sulfamethylisoxazole 0.4 g and trimethoprim 0.08 g) per day. Cerebrospinal fluid (CSF) smear showed no bacteria, but CSF culture grew a branched Gram-positive rod organism on day 9, which was identified as Nocardia cyriacigeorgica. Follow-up CT brain at 6 weeks showed significant reduction in the size of the brain lesions. She was continued on the treatment and a repeat CT scan at 6 months showed complete resolution of the brain lesions [Figure 2]. | Figure 1: (a) Cranial CT showing abscesses in the right occipital lobe, (b) Cranial CT showing abscesses in the left cerebellum
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 | Figure 2: (a) Cranial CT showing no abscesses in the right occipital lobe, (b) Cranial CT showing no abscesses in the left cerebellum
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Nocardiosis is an unusual opportunistic infection in humans. [4] In this patient, pure red cell aplasia and diabetes mellitus were the predisposing risk factors for the infection. The most frequent initial site of nocardiosis is the lung through inhalation of airborne bacteria. [5] Infection with N. cyriacigeorgica may result from direct traumatic inoculation into the skin and then to brain though hematogenous spread. In immunocompromised individuals with multiloculated ring-enhancing brain lesions, nocardiosis should be suspected. The clinical features and imaging findings of nocardial brain abscesses are nonspecific, and CSF examination may not be of particular help. Moreover, the growth of nocardial species is slow, normally appearing within 2-7 days in most routine bacteriologic media, even taking 2-3 weeks. [5] Waiting for the result of culture to institute the appropriate antibiotics would delay the best chance of treatment. When the diagnosis of nocardial infection is strongly suspected, smear examination of the aspirate for nocardial infection should be done and the patient should be started on the empiric therapy. There is no standard treatment strategy for nocardial brain abscess. [6] Most clinicians reported success in treating nocardial brain abscess by aspiration and excision followed by prolonged antibiotic therapy. [7],[8] Our patient had cure with prolonged antibiotic therapy without surgery, and the other unique feature in our patient is occurrence of brain lesions on both the sides.
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