Category: Clinical Sciences/Health Conditions
Case Diagnosis: Disseminated Miliary Nocardiosis
56-year-old male with history of alcohol use presented with 1-month insidious onset of confusion. Brain magnetic resonance imaging (MRI) demonstrated innumerable ring-enhancing lesions in cortical, subcortical, and cerebellar structures. Chest imaging demonstrated necrotic left upper lung lobe and mediastinal masses concerning for malignancy. Work-up notable for persistent lymphopenia, co-existent Lyme’s disease and negative human immunodeficiency virus testing. Hospital course complicated by cerebral edema, non-convulsive status epilepticus, respiratory failure, and tracheoesophageal fistula. Endobronchial biopsy and blood cultures were positive for Nocardia Farcinica treated with Linezolid, Meropenem, and Bactrim. Neurologic examination remarkable for left gaze preference, delayed processing, impaired memory, and bilateral proximal weakness. Initial functional assessment demonstrated maximum assistance for transfers, poor balance, and total assistance for self-care activities of daily living.
The well-documented differential diagnosis for ring-enhancing lesions on brain MRI includes tuberculomas, abscesses, septic emboli, malignancy, cysticercosis, toxoplasmosis, and nocardiosis. Nocardia farcinica is a gram-positive, partially acid-fast, aerobic actinomycete, which is opportunistic and the least common of the Nocardia spp. Multifocal brain abscess formation from disseminated Nocardia spp is responsible for 2%–20% of brain abscesses in immunocompromised hosts, with those affected by Nocardia farcinica having mortality rate of 7%-85%. The lungs(40%) and brain(22%) are most commonly affected. The incidence for neurologic impairment following brain abscess survival is 20%-70%. Our patient had significant functional and neurologic deficits associated with pulmonary deconditioning, dysphagia, and evidence for critical illness myopathy related to his complicated medical course.
Andrew McCoy– Resident, University of Pittsburgh Medical Center
Joseph Staszel– Resident Physician, University of Pittsburgh Medical Center, Department of Physical Medicine & Rehabilitation
Kerry Deluca– Assistant Professor, University of Pittsburgh Medical Center