gms | German Medical Science

Objective: Cerebral nocardiosis is rare and represents a severe infection leading to high mortality despite antibiotic therapy. We report a unique case of a brain abscess in the left basal ganglia caused by Nocardia farcinica in an immunosuppressed patient with Wegener’s granulomatosis.

Method: A 66-year-old man presented with right-sided hemiparesis in our hospital. Cranial magnetic resonance imaging (MRI) showed a circular contrast enhancing lesion in the left basal ganglia with a significant surrounding edema, consistent with a malignant tumor. Stereotactical biopsy through a frontal burr hole led to the detection of Nocardia farcinia identified by polymerase chain reaction and culture. Intravenous antibiotic therapy with amikacin and imipenem according to antimicrobial susceptibility testing was initiated and the immunosuppressive therapy was paused. Screening tests for the activity of the Wegener’s granulomatosis were performed regularly (urine sediment, antibodies, thoracal, and abdominal CT-scans). For the activity of the brain abscess native and contrast enhanced cranial MRI were arranged every 6 weeks.

Results: The intravenously applicated antibiotic therapy was continued for one year using a port system in the cephalic vein allowing the patient to be dismissed from hospital. During the 12 months-treatment, a decreasing size of the contrast enhancing lesion was seen by MRI, which was accompanied by clinical improvement of the right sided hemiparesis. After finishing the antibiotics no recurrence of the abscess could be seen in cranial MRI.

Conclusions: As nocardioses are infectious diseases of immunosuppressed patients and, thus, the number of those patients is increasing, this case highlights the growing importance of nocardioses to be considered as a possible pathogenic agent even in neurosurgery. Bearing in mind the poor outcome of nocardia brain abscesses, it is crucial to treat the patients according to antibiogram and over a sufficient time period.