Nocardiosis with Central Nervous System Dissemination from Non-prescribed High-dose Prednisone Use
Raman Shrestha1, Alan Spicer2, Kristopher Grajny1
1Lehigh Valley Fleming Neuroscience Institute, 2University of South Florida Morsani College of Medicine
Background:
Infection with Nocardia species is rare and more commonly seen in immunocompromised patients. With nocardiosis, there is a high risk of dissemination to the central nervous system and can lead to brain abscesses or meningitis. Overall, the prognosis is poor with 1-year mortality between 29 to 52% and even higher with central nervous system involvement.
Design/Methods:
Not applicable
Results:
A 44-year-old female presented to the hospital for three months of progressively worsening lower extremity weakness and one month of intermittent paresthesia of distal extremities. For 2 months, she had been self-treating her sciatica with 200 mg daily prednisone obtained from an online pharmacy without a proper prescription. Brain and cervical spine MRI showed multiple scattered T2 hyperintense lesions without enhancement that were concerning for demyelinating disease. Her weakness was attributed to steroid-induced myopathy. She declined lumbar puncture and was discharged with B12 supplementation and steroid taper. Two months later, she went to the hospital for three weeks of dizziness and fatigue. CT head showed scattered multifocal hypodense lesions, and CT abdomen and pelvis showed renal vein thrombus and multiple other disseminated lesions. Brain MRI showed diffuse multiple cerebral and cerebellar cystic enhancing lesions without hydrocephalus. Blood cultures were positive for Nocardia farcinica, and she was promptly started on antibiotics. She underwent needle aspiration of intracranial abscesses, and intraoperative cultures also grew Nocardia farcinica. On discharge, she was continued on prolonged antibiotics with a decrease in the size of intracranial abscesses on follow-up imaging. Her sciatic pain was managed with methocarbamol and lidocaine patches.
Conclusions:
Infection with Nocardia species is rare but dangerous with high mortality rates. This case highlights the importance of keeping nocardiosis as a differential for central nervous system infections, especially in the age of developing immunotherapies and accessibility of steroids through online pharmacies without prescriptions.
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