Case 4: a 84-year-old male with HCV chronic infection and associated cryoglobulinemia in long Four Cases of Cerebral Nocardiosis term steroid treatment. He had several domestic accidents due to right homonymous inferior M.Annovazzi Lodi*, M.C. Leoni*, M.Mussa*, A.M. Di Matteo*, L. Minoli * quadrantanopia. Dipartimento di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo – Università di Pavia The MRI study showed 2 multiloculated lesions with post-contrast enhancement and peripheral oedema in the left occipital lobe. CT scan of the lung was Background: Cerebral nocardiosis is a rare Microbiological analysis of blood and CSF resulted Case 3: A 80-year-old male patient with Horton negative as well as lumbar puncture. Craniotomy opportunistic infectious disease of the CNS with high negative except for a positive anti-Toxoplasma IgM disease in chronic treatment with oral steroids and with abscess evacuation was performed. Cultures mortality primarily in immunocompromised hosts. serology. methotrexate was admitted for fever, disorientation were positive for Nocardia and treatment with Nocardial infection is acquired through inhalation or Under suspected diagnosis of toxoplasmosis, and dementia symptoms. intravenous TMP/SMX + Ceftriaxone was started. cutaneous inoculation and can spread hemato- treatment with sulfadiazine/pyrimethamine was We performed lumbar puncture without evidence of Three days later the patient suffered of weakness of genously to the CNS. Nocardial intraparenchymal started without any clinical or radiological alterations. A whole body CT showed a lung lesion the right side limbs and instable walk. We repeated abscesses represent only 2% of all cerebral abscesses improvement after two weeks. in the upper right lobe suggesting malignancy. Brain the brain CT scan which demonstrated bleeding in but have a mortality three times higher than those of Craniotomy with abscess evacuation was performed MRI demonstrated multiple intraxial lesions with the biopsy site and multiple satellite lesions. After 2 other bacterial etiology. Surgical excision of the but bacteriological cultures and histopathological enhancement after contrast administration, months of intravenous antimicrobial treatment he abscess reduces the mass effect and provides examination resulted negative. A 4 week broad- suggestive for abscesses. was transferred to the inpatient rehabilitation unit bacteriological diagnosis enabling a prompt organism- range empirical antimicrobial therapy with We stopped steroids administration and started an where he unfortunately died. specific antimicrobial therapy. Meropenem and Linezolid was started obtaining empirical antimicrobial therapy with Linezolid + clinical and radiological improvements. Meropenem. Conclusions: Nocardial brain abscess is a rare Material/methods: A retrospective cohort study. Six months after the abscess biopsy, we received a We repeated the thoracic CT after 4 weeks of condition that needs to be differentiated from other We reviewed the charts of all patients with nocardial positive report for Nocardia spp from panbacterical empirical therapy achieving an important reduction brain lesions. brain abscess in the Infectious Disease Department PCR performed at the Zooprophylactic Institute of of the lung nodule. Nocardial identification can be challenging. The of San Matteo Medical Center, a University Hospital Pavia. Another 4 week antibiotic treatment was Under suspect of nocardiosis the antimicrobial association of pulmonar lesions and cerebral abscess in Italy, between the years 2012 and 2015. started with Linezolid and Ceftriaxone achieving therapy was switched to TMP/SMX. We planned for in immunocompromised patients may evoke a reduction and then disappearance of brain lesions. a biopsy of one of the brain lesions but the patient nocardial etiology. The patient is still in clinical and radiological follow- condition worsened and he died. Surgical excision of the lesions has a primary role up with no evidence of relapse after 3 years. Seven months later we received the report of the providing the bacteriological diagnosis. post-mortem histopathological examination positive Even with a correct diagnosis and targeted therapy, Case 2: a 74-year-old male with anamnesis of CLL for Nocardia spp. prognosis is severe. In good responder patients in long term treatment with steroids was admitted prolonged antimicrobial therapy and long-term to our hospital with symptoms of sight impairment. surveillance are needed to prevent relapse. A brain CT showed a lesion in the left occipital lobe suggesting abscess or metastasis. A thoracic CT scan revealed another nodule. High-dose steroid treatment was started but after few days the neurological conditions worsened. Another brain CT was made showing an increased subdural effusion requiring surgical drainage. We obtained purulent specimens and started antimicrobial Case 1: A 69- year-old woman, heart transplanted, empirical therapy and antiepileptic prophylaxis. The was admitted due to fever, headache and confusional bacteriological cultures were positive for Nocardia state. She had over 6 months oral treatment of brasiliensis and therapy was switched to TMP/SMX + methylprednisolone, MMF and CSA after heart Meropenem. transplant for DCM. After initial improvement the patient suffered of CT brain study showed multiple subcortical lesions progressive deterioration with pancitopenia, which with central necrosis and peripheral ring forced us to stop TMP/SMX administration, and enhancement after contrast administration, suggestive eventually he died of septic shock. of opportunistic infection. Lumbar puncture was performed resulting with normal cell count.

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