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Disseminated nocardiosis with cerebral and subcutaneous lesions on low-dose prednisone
  1. Kedar R Mahajan
  1. Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH 44195, USA
  1. Correspondence to Dr Kedar R Mahajan, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH 44195, USA; mahajak{at}ccf.org

Abstract

This case report is of a septuagenarian man on chronic low-dose prednisone who presented with disseminated nocardiosis (Nocardia cyriacigeorgica) that was initially mistaken for metastatic brain cancer. Neurologists should be aware of the potential for opportunistic infections with steroid use and to consider a definite tissue diagnosis with culture and histopathology prior to treatment.

  • nocardia
  • nocardiosis
  • disseminated
  • brain lesions
  • immunosuppression
  • metastasis.

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A septuagenarian man presented with a 6-week history of progressive malaise, decreased appetite, proximal lower extremity weakness and leg spasms. He had chronic obstructive pulmonary disease and pulmonary silicosis (attributed to sandblasting for 30 years in an autoshop) and was taking long-term prednisone 10 mg daily. While in hospital he developed progressive limb weakness (particularly right-sided) and confusion. CT scan of the head showed multiple ring-enhancing brain lesions (figure 1), thought to be cerebral metastasis. CT scan of the chest, abdomen and pelvis found multiple subcutaneous and intramuscular infiltrative masses, the largest being lateral to the right iliac wing (figure 2).

Figure 1

CT with intravenous iodinated contrast shows axial views of the brain and multiple ring-enhancing intracranial lesions with surrounding oedema.

Figure 2

Abdominopelvic CT with intravenous iodinated contrast with a large cystic mass lateral to the right iliac wing.

The presumptive diagnosis was metastatic cancer and he was given empirical whole-brain radiation treatment.

Fine-needle aspiration of the right thigh mass later revealed branching filamentous bacteria, and tissue nocardia cultures grew Nocardia cyriacigeorgica. His right thigh mass fluid and blood cultures grew Burkholderia multivorans. He was treated with meropenem, linezolid and sulfamethoxazole/trimethoprim for disseminated nocardiosis and B. multivorans. Unfortunately, he developed complications from pneumonia, septic shock and acute respiratory failure requiring mechanical ventilation, and died following pulseless electrical activity cardiac arrest.

Nocardia may cause deep skin and soft tissue abscesses and pulmonary disease,1 and an immunosuppressed state2 is an important risk factor.

Key Points

  • Disseminated nocardiosis, which typically causes soft tissue and pulmonary lesions in immunosuppressed patients, sometimes may mimic brain metastases.

  • Burkholderia, also associated with pulmonary disease and immunosuppression, may cause meningitis but not brain lesions.

  • When suspicious lesions are biopsied, clinicians should request culture and histopathology to obtain a definitive diagnosis before starting empirical treatment.

  • Considering nocardia as a potential cause of similar presentations may improve the likelihood of improvement.

References

View Abstract

Footnotes

  • Contributors KRM conceived and wrote the manuscript.

  • Funding KRM is funded by a National Multiple Sclerosis Society Clinician Scientist Development Award (FAN-1507-05606).

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Provenance and peer review. Not commissioned. Externally peer reviewed by Nicholas Davies, London, UK.

  • Data sharing statement Available data are presented in the manuscript with protected health information withheld.

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