Nocardiosis (central nervous system manifestations)

Last revised by Daniel J Bell on 13 Jun 2022

Central nervous system (CNS) nocardiosis is a rare infection that may affect both the brain and the spine in patients with immunodeficiency. 

CNS nocardiosis has been reported to represent ~2% of all cerebral abscesses, and to be present in 15-50% of patients with systemic infection 2-3

Symptoms may vary according to the type of presentation and its extension in the CNS: headache, nausea, vomiting, focal neurological deficit and seizures are reported as the most common 2-3

Nocardia spp. are aerobic gram-positive bacilli which are ubiquitous saprophytic organisms 1-3. The infection is acquired primarily by inhalation of the bacillus from the environment, from where it can spread hematogenously to other organs and tissues 1-2. In the CNS the infection manifests as meningitis, granuloma with giant cells or cerebral abscesses 2

Identification of Nocardia spp. in the clinical laboratory can be challenging: the organism may grow on cultures in intervals between 4 days to 2–4 weeks 1.

This infection has no specific features to aid in suggesting the diagnosis. It typically manifests as a parenchymal abscess in any part of the brain, though spinal cord abscesses and meningitis have also been described 1,2.

Medical and surgical opinions should be sought 4,5. Empiric antibiotic treatment consists of trimethoprim-sulfamethoxazole plus either a carbapenem class antibiotic and/or amikacin 4, while surgical management includes craniotomy or aspiration of abscesses 4,5. Both craniotomy and aspiration have been found to be equally effective 5.

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