Cerebral Nocardiosis: a diagnostic challenge

Abstract

uncertain if this represented post-surgical change, residual neoplasm, radiation reaction, or infection. One-year after the brain mass resection, the patient presented to the hospital with new-onset expressive aphasia and focal weakness in the left lower extremity. Repeat MRI showed 3 new ring- enhancing lesions within the left cerebellum, left temporo-parietal junction, and left para-median superior parietal lobe (Figure 1). There was persistent irregular enhancement within the right cerebellum, now extending to the right middle cerebellar peduncle. Aspiration biopsy revealed a large amount of Nocardia farcinica, which was resistant to ceftriaxone, imipenem, clarithromycin, tobramycin, doxycycline, and minocycline. The patient was started on trimethoprim- sulfamethoxasole 400 mg three times/day, but despite continued antibiotic treatment, she became bacteremic. This was complicated by acute toxic