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Wang X, Yang H, Xie Y, Xian X. Severe disseminated Nocardia brasiliensis pneumonia with normal immune function: A case report. Medicine (Baltimore) 2024; 103:e36402. [PMID: 38181241 PMCID: PMC10766318 DOI: 10.1097/md.0000000000036402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/10/2023] [Indexed: 01/07/2024] Open
Abstract
RATIONALE Members of the genus Nocardia brasiliensis are Gram-positive, aerobic bacteria and exist ubiquitously in most environments. In recent years, the incidence of Nocardia brasiliensis has increased significantly and become a global concern. It may be predominantly caused pulmonary infections in immunocompromised hosts. Interestingly, however, we found that it can be present not only on immunocompromised hosts, but also to infect patients with a normal immune system. PATIENT CONCERNS We report a very rare case of a 49-year-old immunocompetent man with disseminated Nocardia brasensis pneumonia. He had a fever for 14 days (maximum temperature about 38°C) and a history of mass rupture. DIAGNOSES Severe Disseminated Nocardia brasiliensis pneumonia with normal immune function. INTERVENTIONS No. OUTCOMES The patient was finally diagnosed with Severe Disseminated Nocardia brasiliensis pneumonia and received compound sulfamethoxazole treatment for 4 months. LESSONS SUBSECTIONS Our report highlights when cold pus appears in soft tissues such as the lower limbs, neck, nose, scalp, etc, should prompt timely evaluation and biopsy for definitive diagnosis. Be alert to a normally immunocompetent, disseminated Nocardia brasiliensis infection. Early recognition and effective treatment are necessary conditions for successful results. This would allow for better disease prognostication while enabling physicians to develop more effective treatment strategies.
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Affiliation(s)
- Xiaobin Wang
- Department of General Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Hongjun Yang
- Department of General Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Yunbo Xie
- Department of General Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Xuejiao Xian
- Department of general surgery, Chuxiong Yi Autonomous Prefecture People’s Hospital, Lucheng Town, Chuxiong City, Chuxiong Yi Autonomous Prefecture, Yunnan Province, China
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Scheitler KM, Bauman MMJ, Carlstrom LP, Graffeo CS, Meyer FB. Nocardia farcinica pituitary abscess in an immunocompetent patient: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22266. [PMID: 36317239 PMCID: PMC9624156 DOI: 10.3171/case22266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pituitary abscess is a rare clinical entity, typically precipitated by Staphylococcus, Pseudomonas, or Aspergillus infection. Although Nocardia species–associated central nervous system abscesses have been documented in immunocompromised patients, no case of Nocardia pituitary abscesses has been previously reported. OBSERVATIONS A 44-year-old man presented with hemoptysis and was found to have a cavitary right lung nodule, which was presumed histoplasmosis, prompting antifungal treatment. Several months later, he developed panhypopituitarism. Magnetic resonance imaging identified a pituitary mass, which subsequently underwent transsphenoidal endoscopic biopsy. Infectious workup was negative, and the patient was discharged on intravenous ertapenem therapy. Over several months, he developed progressive headaches, and updated imaging confirmed interval enlargement of the mass with new cavernous sinus invasion. He underwent repeat endoscopic biopsy, which yielded positive cultures for Nocardia farcinica and prompted successful treatment with trimethoprim-sulfamethoxazole and linezolid. LESSONS The current study highlights a previously unreported clinical entity, the first pituitary abscess attributable to Nocardia sp. or N. farcinica, which arose in a young, immunocompetent individual. Although rare, atypical infections represent an important component in the differential diagnosis for sellar mass lesions.
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Affiliation(s)
| | | | | | - Christopher S. Graffeo
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota,Barrow Neurological Institute, Phoenix, Arizona; and ,Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Fredric B. Meyer
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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Pan L, Pan XH, Xu JK, Huang XQ, Qiu JK, Wang CH, Ji XB, Zhou Y, Mao MJ. Misdiagnosed tuberculosis being corrected as Nocardia farcinica infection by metagenomic sequencing: a case report. BMC Infect Dis 2021; 21:754. [PMID: 34348670 PMCID: PMC8335456 DOI: 10.1186/s12879-021-06436-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background Disseminated nocardiosis is liable to be misdiagnosed owing to the non-specific clinical manifestations and laboratory/imaging findings. Metagenomic next-generation sequencing (mNGS) is a culture-independent and rapid method for direct identification of all microorganisms in clinical specimens. Case presentation A 72-year-old man was admitted to our hospital on February 20, 2019 with a history of recurrent cough, expectoration, fever, and diarrhea since 1 month, and unconsciousness since 1 week. Contrast-enhanced magnetic resonance imaging of head showed multiple lesions in the bilateral cerebral hemispheres, brainstem, and cerebellar hemispheres. The presumptive diagnosis was disseminated tuberculosis, although all tests for mycobacterium were negative. However, the patient did not benefit from antituberculosis treatment. Repeat MRI showed multiple abnormal signals in the brain and progression of meningeal thickening. Cerebrospinal fluid and bronchoalveolar lavage fluid specimens were subsequently sent for PMSeq metagenomics sequencing; the results indicated Nocardia. farcinica as the predominant pathogen. The anti-TB treatment was stopped and the patient was prescribed sulphamethoxazole in combination with linezolid and meropenem for nocardiosis. He showed gradual neurological improvement and was transferred to Huashan Hospital. He was discharged from the hospital on April 19, 2019, but died of persistent diarrhea on May 26, 2019. Conclusions Patients with suspected nocardiosis do not always respond to conventional treatment; therefore, mNGS can facilitate diagnosis and timely treatment decision-making.
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Affiliation(s)
- Lei Pan
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Xiao-Hong Pan
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Jie-Kun Xu
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Xiao-Qing Huang
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Jun-Ke Qiu
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Cai-Hong Wang
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Xiao-Bo Ji
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China
| | - Yang Zhou
- BGI PathoGenesis Pharmaceutical Technology, BGI-Shenzhen, Shenzhen, 518083, China
| | - Min-Jie Mao
- Department of Tuberculosis Intensive Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng Dong Road, Hangzhou, 310003, China.
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Sun H, Goolam Mahomed M, Patel J. Brain metastasis or nocardiosis? A case report of central nervous system Nocardiosis with a review of the literature. J Community Hosp Intern Med Perspect 2021; 11:258-262. [PMID: 33889333 PMCID: PMC8043543 DOI: 10.1080/20009666.2021.1877399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Nocardiosis is an infection caused by the gram-positive bacterium Nocardia, which typically manifests as an isolated pulmonary or systemic disease. Of note, Nocardia has a predilection for the central nervous system (CNS) involvement, which is more commonly seen in systemic nocardiosis rather than as an isolated CNS infection. According to the Centers for Disease Control and Prevention, the estimated incidence of nocardiosis is only 500 to1000 cases in the USA every year, with cases mostly found in immunocompromised people, although infection in the immunocompetent may also occur. Here, we present a case of an immunocompromised patient who presented with neurologic symptoms and intracranial lesions initially concerning metastatic disease. Upon further investigation, the patient was found to have CNS nocardiosis with bacteremia. This is an extremely rare presentation given the lack of concurrent pulmonary and cutaneous involvement. The insidious onset and rarity of nocardiosis can result in a delayed or missed diagnosis. Early recognition is crucial as this is a potentially life-threatening illness. After obtaining adequate culture specimens, empiric treatment must be started expeditiously, keeping in mind the diversity of the Nocardia species and their antimicrobial resistance patterns.
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Affiliation(s)
- Hojin Sun
- Department of Medicine, Graduate Medical Education, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Mariam Goolam Mahomed
- Department of Medicine, Graduate Medical Education, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Jaimin Patel
- Department of Medicine, Graduate Medical Education, Methodist Dallas Medical Center, Dallas, TX, USA
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Grond SE, Schaller A, Kalinowski A, Tyler KA, Jha P. Nocardia farcinica Brain Abscess in an Immunocompetent Host With Pulmonary Alveolar Proteinosis: A Case Report and Review of the Literature. Cureus 2020; 12:e11494. [PMID: 33354440 PMCID: PMC7744209 DOI: 10.7759/cureus.11494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 55-year-old immunocompetent male presented with new-onset seizures and acute respiratory failure requiring intubation and a stay in the medical intensive care unit. Magnetic Resonance Imaging (MRI) of the brain revealed ring-enhancing lesions, and Computed Tomography (CT) chest showed ground-glass opacity. The patient underwent craniotomy and bronchoscopy, followed by culture of the purulent aspirate from lesions in the brain and bronchoalveolar lavage (BAL). After extensive infectious workup, the patient was diagnosed with a Nocardia farcinica brain abscess plus underlying pulmonary alveolar proteinosis (PAP). Based on a recommendation from an infectious disease expert, the patient was treated with trimethoprim-sulfamethoxazole (TMP/SMX). This case highlights the importance of understanding that, though rare, infections such as nocardiosis can present in immunocompetent patients and cause severe morbidity.
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Affiliation(s)
- Sarah E Grond
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | | | | | | | - Pinky Jha
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
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Livings C, Uemura M, Patel R, Afshar M. Nocardia farcinica masquerading as intracerebral metastases in advanced metastatic prostatic cancer. BMJ Case Rep 2020; 13:13/9/e233678. [PMID: 32900716 DOI: 10.1136/bcr-2019-233678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old man with metastatic prostate cancer and underlying asymptomatic pancytopenia presented with a 1-week history of general malaise, left leg weakness and facial numbness. Initial brain imaging demonstrated two rim-enhancing lesions felt to represent intracerebral metastasis. Following neurosurgical referral, a multidisciplinary meeting decision was made for best supportive care and dexamethasone was given. He developed multiple cutaneous lesions, which on incision and drainage revealed Nocardia farcinica Repeat brain imaging showed enlargement of the existing cavitating lesions and appearance of new lesions, now typical of cerebral abscesses. A diagnosis of disseminated nocardiosis with cutaneous and intracerebral infection was reached. He started taking empirical treatment with intravenous meropenem, co-trimoxazole and subsequent addition of amikacin, with little improvement. On further review of sensitivities, moxifloxacin was added. Following over 1 month of antimicrobial treatment, his neurological symptoms, cutaneous lesions and repeat MRI of the brain had improved.
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Affiliation(s)
- Claire Livings
- Department of Oncology, University of London Saint George's, London, UK
| | - Mayu Uemura
- Department of Oncology, University of London Saint George's, London, UK
| | - Reena Patel
- Department of Oncology, University of London Saint George's, London, UK
| | - Mehran Afshar
- Department of Oncology, University of London Saint George's, London, UK
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Kweh BTS, Lee HQ, Tee JW. Intracranial peripherally enhancing lesions in cardiac transplant recipients: A rare case series and literature review. J Clin Neurosci 2020; 78:284-290. [PMID: 32331940 DOI: 10.1016/j.jocn.2020.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/05/2020] [Indexed: 12/26/2022]
Abstract
Intracranial peripherally enhancing lesions in immunosuppressed solid organ transplant recipients represent a unique diagnostic and management dilemma due to the vast array of differentials that demand consideration. Diagnosis of the underlying pathology is often guided by the use of magnetic resonance imaging (MRI). We present the first published case series of three cardiac transplant recipients with significantly atypical neuroradiological findings contrary to the tenets of contemporary literature. Our rare case series consists of: (1) A sterile Mycobacterium pyogenic abscess mimicking glioblastoma multiforme due to an immunosuppressed state (2) Epstein Barr Virus encephalitis masquerading as Central Nervous System Post-Transplant Lymphoproliferative Disorder (3) An unusual case of partially treated disseminated Nocardiosis warning of the need to consider the immunosuppressed state and partial treatment response obfuscating classical MRI appearances. We utilise these unprecedented cases as the basis of a literature review to understand the pathophysiology behind the peculiar imaging findings in this rarefied cohort of transplant recipients, and rationalise why the MRI findings in each instance contradicts the accepted imaging patterns. In the setting of potential unreliability of neuroradiology in this immunosuppressed unique subgroup, we hope to impart to clinicians that definitive diagnosis obtained by emergent neurosurgical intervention may be necessary to accurately and expediently guide further medical management.
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Affiliation(s)
- Barry Ting Sheen Kweh
- National Trauma Research Institute, Melbourne, Victoria 3004, Australia; Department of Neurosurgery, Level 1, Old Baker Building, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Hui Qing Lee
- National Trauma Research Institute, Melbourne, Victoria 3004, Australia; Department of Neurosurgery, Level 1, Old Baker Building, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Jin Wee Tee
- National Trauma Research Institute, Melbourne, Victoria 3004, Australia; Department of Neurosurgery, Level 1, Old Baker Building, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
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Dash D, Das P, Bhargava A, Gaikwad UN, Negi SS, Wankhede A. Estimating the burden of enteric fever in Chhattisgarh: A single-center study on culture-positive cases from a newly built tertiary care hospital. J Lab Physicians 2020; 11:234-239. [PMID: 31579242 PMCID: PMC6771319 DOI: 10.4103/jlp.jlp_154_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Enteric fever is the most common cause of community acquired blood stream infections in under developed and developing countries. The enteric fever is exclusive to humans and transmitted through the faeco-oral route. Though India is an endemic zone for enteric fever, the data is very scarce from Central India. The present study was undertaken to determine the prevalence of enteric fever in this region and to know the antimicrobial susceptibility pattern of the isolated typhoidal Salmonellae. MATERIAL AND METHOD We conducted a retrospective analysis of blood culture positive cases of enteric fever over a period of two years (December 2015 to December 2017). All blood cultures submitted for suspected enteric fever and associated symptoms were included in the study. Relevant demographic, clinical and laboratory data were analyzed. RESULT A total of 51 cases (3.56%) were of typhoidal Salmonella from a total of 1430 blood culture submission. Salmonella Typhi were 70.5% while Salmonella Paratyphi A were 29.5% of the total isolated Salmonellae. The most vulnerable age group was 10-19years (41.2%). The mean minimum inhibitory concentration of ciprofloxacin for Salmonella Typhi and Salmonella Paratyphi A are 1.20 and 1.97 μg/ml respectively. All the isolates were susceptible to ceftriaxone. Highest isolation was in the July - September quarter (35.3%). CONCLUSION There is a high prevalence of the disease which needs urgent focus on safe water, sanitation services and also to establish guidelines for empiric therapy for enteric fever.
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Affiliation(s)
- Debabrata Dash
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Padma Das
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Anudita Bhargava
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Ujjwala Nitin Gaikwad
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Sanjay Singh Negi
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Archana Wankhede
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Quinoa T, Jumah F, Narayan V, Xiong Z, Nanda A, Hanft S. Nocardia amikacinitolerans and cytomegalovirus: distinctive clinical and radiological characterization of the rare etiologies of brain abscesses: report of 2 cases. Neurosurg Focus 2019; 47:E18. [PMID: 31370021 DOI: 10.3171/2019.5.focus19284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
Central nervous system infections in immunosuppressed patients are rare but potentially lethal complications that require swift diagnoses and intervention. While the differential diagnosis for new lesions on neuroradiological imaging of immunosuppressed patients typically includes infections and neoplasms, image-based heuristics to differentiate the two has been shown to have variable reliability.The authors describe 2 rare CNS infections in immunocompromised patients with atypical physical and radiological presentations. In the first case, a 59-year-old man, who had recently undergone a renal transplantation, was found to have multifocal Nocardia amikacinitolerans abscesses masquerading as neoplasms on diffusion-weighted imaging (DWI); in the second case, a 33-year-old man with suspected recurrent Hodgkin's lymphoma was found to have a nonpyogenic abscess with cytomegalovirus (CMV) encephalitis.As per review of the literature, this appears to be the first case of brain abscess caused by N. amikacinitolerans, a recently isolated superbug. Despite confirmation through brain biopsy later on in case 1, the initial radiological appearance was atypical, showing subtle diffusion restriction on DWI. Similarly, the authors present a case of CMV encephalitis that presented as a ring-enhancing lesion, which is extremely rare. Both cases draw attention to the reliability of neuroimaging in differentiating an abscess from a neoplasm.
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Affiliation(s)
| | | | | | - Zhenggang Xiong
- 2Pathology and Laboratory Medicine, Rutgers-Robert Wood Johnson Medical School and University Hospital, Rutgers University, New Brunswick, New Jersey
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Shimizu Y, Tsuchiya K, Fujisawa H. Nocardia paucivorans cerebellar abscess: Surgical and pharmacotherapy. Surg Neurol Int 2019; 10:22. [PMID: 31123629 PMCID: PMC6416759 DOI: 10.4103/sni.sni_370_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/20/2018] [Indexed: 11/04/2022] Open
Abstract
Background Nocardia species are ubiquitous in nature and mainly cause pulmonary disease in humans; however, they can also infect the central nervous system and skin. The management of cerebellar nocardiosis is troublesome and requires multiple considerations of the severity of the underlying systemic disease, difficulties in identifying the bacterium, and frequent delay in initiating adequate therapy. Case Description We report a 52-year-old diabetic female patient with Nocardia paucivorans cerebellar abscesses. Brain magnetic resonance imaging (MRI) revealed innumerable small ring-enhancing lesions of posterior fossa. In this report, we present a case of primary single cerebellar abscesses due to N. paucivorans. Early diagnosis and surgical interventions were significant for the patient. The diagnosis was confirmed by DNA sequencing and the organism was susceptible to trimethoprim-sulfamethoxazole (TMP/SMX). The patient was successfully treated with drugs and surgical excision. Conclusion According to the literature, surgical excision or aspiration of cerebellar abscess seems to provide favorable outcomes. In our experience, a successful outcome was achieved with subtotal resection and prolonged adequate antibiotic therapy.
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Affiliation(s)
- Yu Shimizu
- Department of Neurosurgery, Kanazawa Medical Center, Kanazawa, Japan
| | | | - Hironori Fujisawa
- Department of Neurosurgery, Kanazawa Medical Center, Kanazawa, Japan
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Bhargava A, Kombade S, Dash D, Jain Y. Disseminated nocardiasis by Nocardia farcinica: Review and first case report from Central India. Med J Armed Forces India 2019; 75:106-111. [PMID: 30705489 DOI: 10.1016/j.mjafi.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Anudita Bhargava
- Additional Professor (Microbiology), All India Institute of Medical Sciences, Raipur 492099, Chhattisgarh, India
| | - Sarika Kombade
- Assistant Professor (Microbiology), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Debabrat Dash
- Senior Resident (Microbiology), All India Institute of Medical Sciences, Raipur 492099, Chhattisgarh, India
| | - Yogesh Jain
- Consultant (Pediatrics), Jan Swasthya Sahyog, Ganiyari, Bilaspur, Chhattisgarh, India
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