Nocardia Brain Abscess:2 Cases Report And Review Of The Literature

Objective To summarize the clinical characteristics of central nervous system nocardial infection and to discuss the early diagnosis and reasonable treatments,in order to provide reference for the clinical diagnosis and treatment for it.Methods Two cases of nocardia brain abscess treated in our hospital were reported on their clinical manifestation,laboratory and imaging examinations,treatments and outcome.PubMed database was searched with nocardia and brain abscess as the key word from July the2016 to December the 2018,twenty-one articles were retrieved and 23 cases of brain abscess were diagnosed.Results 1.Totally 25 cases of patients who were diagnosed as nocardia brain abscess by pathogenic examination were collected(2 cases of neurology in our hospital and 23 cases of PubMed database),including 20 male cases(80%)and 5 female cases(20%),the age ranged from 35 to 84 years,with an average age of 54.76 years.2.18 cases were classified as immunodeficiency,12 cases received corticosteroids treatment,5 cases received other immunosuppressive agents in addition to corticosteroids and1 case received only immunosuppressive therapy.Among them,there were 5 patients with autoimmune diseases,3 tumors or cancers,2 organ transplants and 2 HIV-positive patients.23 cases were complicated with underlying diseases,8 lung diseases,6 endocrine diseases,5autoimmune diseases,and 4 kidney diseases.3.The main clinical symptoms included headache,fever and limb weakness,headache11 cases(44%),limb weakness 10 cases(40%)and fever 6 cases(24%).Other symptoms included epilepsy 3 cases,altered mental status 2 cases,conscious state change 2 cases,nausea and vomiting 2 cases,language disorder 2 cases,ataxia 2 cases,and visual change 2cases.4.Regarding the laboratory diagnostic techniques,14 patients(56%)were diagnosed with culture of specimens from the site of infection,there were 6 cases of cerebral abscess pus,3 cases biopsy and culture of the brain lesion,2 cases with CSF culture and puncture fluid culture of leg abscess,bronchoalveolar lavage fluid culture and sputum culture in 1 case each.11 cases were confirmed with 16 SrRNA gene sequencing as a species phenotypic identification method.The species was reported in 21 patients and the most frequently isolated species was N.farcinica.5.Eighty-eight percent of all patients were treated with trimethoprim-sulfamethoxazole(TMP-SMX),while 81.82% of them received TMP-SMX in combination with other antibiotics.There were 15 patients underwent neurosurgical interventions,included brain abscess drainage or aspiration in 10 cases and brain abscess excision in 8 cases,and three of them received both types of surgery.15 patients who were treated with both antimicrobial therapy and neurosurgery,of whom only 3 patients died,10 patients who received only antimicrobial therapy,of whom 3 patients died.Conclusion 1.Nocardia infection is more common in patients with immune deficiency and underlying diseases,especially those who have been treated with corticosteroidand or immunosuppressive agents treatment for a long time.2.The diagnosis depends on etiological examination.The specimens can be selected pus,biopsy tissue,cerebrospinal fluid,sputum and so on.It is suggested that the culture time should be prolonged more than 2 weeks.16 SrRNA gene sequencing contributes to early diagnosis.3.TMP-SMX and linezolid are the first choice of drugs for the treatment of nocardiosis infection.It is recommended for at least 12 months.Early neurosurgical intervention can improve the clinical symptoms and prognosis of patients.