Klaudija Višković

Marija Kusulja

Vladimir Krajinović

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Infektolo{ki glasnik 37:1, 31–34 (2017)Croatian Journal of Infection 37:1, 31–34 (2017)ISSN 1331-2820UDK 619.9 31Marija Kusulja, Vladimir Krajinovi}, KlaudijaVi{kovi}University Hospital for Infectious Diseases "FranMihaljevic", Mirogojska cesta 8, Zagreb, CroatiaPrimljeno: 2016–10–12Received: 2016–10–12Prihva}eno: 2016–12–17Accepted: 2016–12–17Nocardiosis is a rare infection with gram-positive aero-bic rods of Nocardia genus. Immunocompromised pa-tients are at increased risk; however, one third of patientsreported to have this infection are immunocompetent. Thefinding of Nocardia in any human sample is always apathological finding. It can cause a localized or dissemi-nated infection of any organ, and can progress despite ade-quate therapy. It can also recur years after successful treat-ment. Antimicrobial treatment usually lasts for 3 months incases of isolated cutaneous infection and 12 months orlonger in central nervous system involvement and in im-munocompromised patients. In patients not responding toantimicrobial therapy, empyema formation and pulmonarynocardiosis with pericarditis, surgical treatment is fre-quently necessary.A 71-year-old male patient presented at the emergencyroom of the University Hospital Centre Zagreb withtwitching of his left arm and left side of face lasting 30minutes, terminating after intravenous application of 10mg of diazepam. He complained of having pins and nee-dles in his left arm for the past two months. His previousImages in Infectious DiseasesSlike u infektivnim bolestimaFigure 1. Preoperative antero-posteriorchest X-ray image revealedmultiple right-sided basal in-filtrates which were consistentwith asymptomatic pulmona-ry nocardiosisNocardia brain abscessesNokardijski mo`dani apscesi32Images in Infectious DiseasesInfektolo{ki glasnik 37:1, 31–34 (2017) medical history included nephrotic syndrome caused byminimal-change disease, for which he had been takingprednisolone for the past 11 years, and iatrogenic diabetesmellitus. He also underwent surgical treatment due to rightknee swelling three months earlier. During preoperativework-up chest X-ray was performed and lung infiltrateswere discovered (Fig. 1). The patient's blood was cultured,revealing Nocardia spp. He was treated with amikacin andthrimetoprim sulfamethoxazole (TMP/SMX) for the nextfive weeks, continuing peroral TMP/SMX after discharge.Since the patient complained of neurological symp-toms at this most recent admission, a native and postcon-trast brain multislice computerized tomography (MSCT)and brain magnetic resonance imaging (MRI) were per-formed, showing multiple brain abscesses (Fig. 2 and 3).According to this finding, the patient was transferred to theUniversity Hospital for Infectious Diseases (UHID) inZagreb. His blood cultures once again grew Nocardia, thistime specified as N. cyriacigeorgica, which was resistantto ciprofloxacin, intermediately susceptible to co-amoxi-Figure 2. Postcontrast brain multislice computerizedtomography (MSCT): bilateral parietal fo-cal lesions measuring 12 mm and 23 mm indiameter with postcontrast right enhance-ment, surrounded with perifocal edemaFigure 3. Brain MRI, A-Fluid AttenuationInversion Recovery (FLAIR) se-quence; B-post contrast T1Weighted Image (WI), revealedmultiple focal lesions with postcontrast ring enhancement (ar-rows) and surrounding edema;consistent with abscesses in pari-etal lobes bilaterallySlike u infektivnim bolestimaInfektolo{ki glasnik 37:1, 31–34 (2017) 33Figure 4. Follow up brain MRI, A-Fluid Attenuation Inversion Recovery (FLAIR) sequence; B-post contrast T1 Weighted Image (WI),showed complete regression of focal lesions and surrounding edema in parietal lobes bilaterallyclav and susceptible to tetracyclines with a MIC of 0.25mcg/mL. Treatment with TMP/SMX, amikacin andimipenem was started, and after six weeks a neurosurgeonwas consulted who saw no indication for surgical inter-vention. The patient was discharged with recommenda-tion to continue peroral therapy with TMP/SMX anddoxycycline. On 7-month follow-up, the patient was sub-jectively well, with no complaints except occasionalfrontal headaches. His follow-up brain MRI showed sig-nificant regression of all brain abscesses, as well as theperifocal edema (Fig. 4). Total planned duration of treat-ment was 2 years.

Slike u infektivnim bolestima: Nokardijski moždani apscesi

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