Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 1053.e15-1053.e24
World Neurosurgery

Case Report
Nocardia farcinica Brain Abscess: Report of 3 Cases

https://doi.org/10.1016/j.wneu.2017.07.033Get rights and content

Background

Central nervous system nocardial infection is a rarely reported disease that usually affects patients with predisposing and debilitating conditions but also the immunocompetent population. The most common variant affecting the brain is Nocardia farcinica. Management of brain nocardiosis is troublesome and requires consideration of the severity of the underlying systemic disease, the difficulties in identifying the bacterium, and the frequent delay in initiating adequate therapy.

Case Description

We present 3 cases of N. farcinica brain abscess (single, multiloculated, and multifocal) diagnosed in 3 patients with predisposing factors that could be successfully cured. The patients underwent craniotomy, evacuation of the purulent collection, and partial resection of the abscesses' walls. Confirmation of N. farcinica species was achieved using specific polymerase chain reaction sequencing of the 16S ribosome RNA gene. Antibiotic therapy was selected on susceptibility tests and was maintained for 10 months (1 case) and 12 months (2 cases).

Conclusions

Brain nocardiosis needs to be suspected primarily (though not exclusively) in immunocompromised patients presenting with neurologic deficit and harboring intracerebral lesions resembling brain tumors. Early identification of the specific species is paramount in order to initiate long-term antibiotic therapy, acknowledging the inherent resistance of N. farcinica to third-generation cefalosporins and its susceptibility to trimethoprim-sulphamethoxazole. According to the literature, surgical excision or aspiration of the brain abscess seems to provide good chances of eradication of the disease. In our experience, successful outcome was achieved with subtotal resection and prolonged and adequate antibiotic therapy.

Introduction

Central nervous system (CNS) nocardial infection is a rare condition that has been increasingly reported in recent years because of the improvement of diagnostic capabilities and a growing susceptible population due to the increasing prevalence of immunosuppression.1, 2 Nocardiosis is a worldwide-distributed actinomycete infection usually acquired by direct inhalation.3 Nocardia genus is an aerobic filamentous gram-positive and weakly acid-fast pathogen that lives as a soil saprophyte.1, 3

CNS involvement is present in about one third of infected patients and is generally attributable to hematogenous dissemination from previous pulmonary disease, skin injury, or operative contamination.3 Nocardia accounts only for 2% of brain abscesses4, 5 and usually affects patients with predisposing and debilitating conditions6, 7 but also the immunocompetent population.4, 8, 9 The most common variant affecting the brain is Nocardia farcinica.3, 10, 11 CNS nocardiosis may present either as meningitis or brain abscess.3 It is considered a serious condition with an overall mortality rate of at least 20%.1, 3, 5, 11 Management of brain nocardiosis is troublesome and requires consideration of the severity of the underlying systemic disease, the difficulties in identifying the bacterium, its inherent resistance to certain antibiotics, and the frequent delay in initiating the adequate therapy.2, 3, 5

A high level of clinical suspicion is necessary in order to identify brain nocardial infection, especially in immunocompetent subjects.6 The mortality rate of patients undergoing inappropriate empirical antibiotic therapy has been reported to be 2 or 3 times higher as compared with those correctly and promptly treated.12 The natural resistance of N. farcinica to some antibiotics, including third-generation cephalosporins, is a key feature to acknowledge when confronting this condition.10 According to previous reports, surgical removal of the purulent collection, including the walls of the abscess, seems to provide a significantly higher survival rate compared with aspiration or drainage alone.1, 5

We present 3 cases of N. farcinica brain abscess diagnosed in 3 patients with predisposing conditions that could be successfully cured. The patients underwent craniotomy, evacuation of the purulent collection, and partial resection of the abscess walls. The pathophysiology, management, and microbiologic particularities of nocardial brain abscess are also reviewed.

Section snippets

Study Sample

We retrospectively reviewed the cases of N. farcinica brain abscess that had been surgically treated at our center from January 2014 to May 2015. Patients' clinical data, medical charts, neuroimaging, and microbiologic findings were retrospectively reviewed. Clinical data were kept confidential at all times, and individual patients could not be identified by their radiologic images. All patients underwent craniotomy, navigation-guided evacuation of the purulent collection, and partial resection

Results

From February 2006 to May 2015, five patients harboring nocardial brain abscesses, 4 males and 1 female, were identified. They were all adults with predisposing conditions. One of the isolates was ultimately identified as N. asteroides, and the patient was therefore excluded. Another patient, who had received navigation-guided aspiration treatment, was lost and no useful follow-up neuroimaging could be obtained, so this case was not included in the study. The main clinical characteristics of

Case 1

A 51-year-old male with a previous history of hypertension, diabetes mellitus treated with oral antidiabetics, dyslipidemia, and previous inguinal hernia and nasal polyp surgery presented with a 2-week history of headache and malaise without fever. The patient had reported right ear fullness and mild self-limited tympanic hemorrhage a few months before admission. Neurologic examination revealed a left inferior visual field defect, left side neglect, left facial palsy, and hemiparesis. Brain MRI

Discussion

Nocardia is a soil-borne, strictly aerobic actinomycete with at least 16 species known to affect humans.11, 14 N. asteroides and N. farcinica are the most commonly identified variants, predominant in zones with temperate climate.11 The genus was named after Edward Nocard, who first isolated the microorganism in 1888 from cattle affected with bovine farcy.3 Epinger reported the first human case in 1890.1 Nocardiosis is predominantly an opportunistic pulmonary disease that tends to disseminate to

Conclusions

In summary, brain nocardiosis needs to be suspected primarily (though not exclusively) in immunocompromised patients presenting with subacute neurologic deficit and harboring space-occupying intracerebral lesions resembling primary or secondary malignant brain tumors. Early identification of the specific nocardial species is paramount in order to initiate long-term effective antibiotic therapy, taking into account the inherent resistance of N. farcinica to third-generation cephalosporins and

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    Conflict of interest statement: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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