Clinical and Radiological Characterization of Central Nervous System Involvement in Nocardiosis: A 20-Year Experience

Razvan M Chirila; Dana Harris; Vivek Gupta; Donna J Hata; Claudiu Matei; Salvador Alvarez; Adrian G Dumitrascu

doi:10.7759/cureus.52950

Clinical and Radiological Characterization of Central Nervous System Involvement in Nocardiosis: A 20-Year Experience

Cureus. 2024 Jan 25;16(1):e52950. doi: 10.7759/cureus.52950. eCollection 2024 Jan.

Authors

Razvan M Chirila¹, Dana Harris¹, Vivek Gupta², Donna J Hata³, Claudiu Matei⁴, Salvador Alvarez¹, Adrian G Dumitrascu⁵

Affiliations

¹ Internal Medicine, Mayo Clinic, Jacksonville, USA.
² Radiology, Mayo Clinic, Jacksonville, USA.
³ Microbiology, Mayo Clinic, Jacksonville, USA.
⁴ Neurological Surgery, Lucian Blaga University, Sibiu, ROU.
⁵ Hospital Medicine, Mayo Clinic, Jacksonville, USA.

Abstract

Background This study aimed to present the clinical and radiological characteristics and the outcomes of patients with Nocardia infection of the central nervous system (CNS). Methodology We conducted a retrospective review of patients aged 18 and older admitted between August 1998 and November 2018 with culture-proven nocardiosis and CNS involvement. Results Out of 110 patients with nocardiosis, 14 (12.7%) patients had CNS involvement. The median age was 54.5 (27, 86) years, and 12 (85.7%) patients were male. Overall, 12 (85.7%) patients were immunosuppressed on high doses of glucocorticoids; seven (50%) patients were solid organ transplant recipients. Only eight (57.1%) patients had neurological symptoms at presentation, and the rest were diagnosed with CNS involvement after imaging surveillance. Three distinct radiologic patterns were identified, namely, single or multiple abscesses, focal cerebritis, and small, septic embolic infarcts. All isolates of Nocardia were susceptible to trimethoprim/sulfamethoxazole and amikacin, with susceptibility to linezolid and carbapenems being 90.9% and 79.5%, respectively. Despite receiving antibiotic therapy, six (42.8%) patients died, most of them within weeks of initial admission. All surviving patients underwent prolonged antimicrobial therapy until the resolution of MRI abnormalities. All solid organ transplant recipients recovered. Conclusions Nocardia CNS infection was a rare condition, even among a large, immunosuppressed patient population. CNS imaging surveillance is paramount for immunosuppressed patients with nocardiosis, as CNS involvement influences the choice and duration of therapy. Nocardia antibiotic susceptibility varied widely between strains and the empiric therapy should consist of multiple classes of antimicrobials with CNS penetration. Mortality was high, but all solid organ transplant recipients recovered.

Keywords: antibiotic susceptibility; bacterial cns infection; cerebral nocardiosis; neurological signs and symptoms; nocardia species.