Brain abcess with "Nocardia Farcinica"

Introduction: Brain abscesses caused by Nocardia farcinica pathogen are rare and usually present as large abscesses with a thick and irregular wall. We present a case of a patient with signs and symptoms of central nervous system infection and had a fulminant evolution with malign cerebral oedema and death. Case report: The 35-year-old patient presented with mild symptoms that appeared 2 weeks prior and became more aggressive in the last 48 hours. After the initial examination and blood tests, the patient was suspected of a systemic infection because of the high white cell count and high level of inflammatory markers. Antibiotic therapy was started with Ciprofloxacin and Amoxicillin/ Clavulanic Acid. The brain MRI showed a multinodular lesion in the right hemisphere, with contrast enhancement and central high diffusion restriction on T1, T2 and FLAIR. During the antibiotic treatment, the patient suddenly became comatose. Urgent brain CT scan showed malign cerebral oedema with brain shift. Discussion: There are 58 documented cases of Nocardia farcinica in the literature, as shown in a recent systematic review. Most of the cases are with immunocompromised patients, either through disease or secondary to treatment after organ transplant. In our case, we suspected immunodeficiencies based on the anamnestic data offered by the patient's family. Mortality rates are between 19% and 36,7% in all reported cases, but in our presented case the patient had a rapid aggressive evolution with malign brain oedema that resulted in death. Conclusions. The management of these cases requires urgent diagnostics and treatment. For our team, the first reported case of Nocardia farcinica and the fast aggressive evolution resulted in a negative outcome, even with antibiotics treatment and surgical evacuation of the abscess.