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Nocardial brain abscess: diagnostic and therapeutic use of stereotactic aspiration
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Surg Neurol 1987;28:114-8
Nocardial Brain Abscess: Diagnostic and Therapeutic Use of Stereotactic Aspiration Walter A. Hall, M.D., A. Julio Martinez, M.D., J. Stephen Dummer, M.D., and L. Dade Lunsford, M.D. Departments of Neurosurgery, Neuropathology, Medicine and Neuroradiology, Hospitals of the University Health Center of Pittsburgh, Pittsburgh, Pennsylvania
Hall WA, Martinez AJ, Dummer JS, LunsfordLD. Nocardial brain abscess: diagnostic and therapeutic use of stereotactic aspiration. Surg Neurol 1987;28:114-8. Three cases of nocardial brain abscess are presented. All three patients were receiving immunosuppressive therapy at the time of diagnosis. Two patients had cardiac transplantation and the third had periarteritis nodosa. The patients presented with generalized seizures or focal weakness. Accurate localization of the intracerebral mass lesion was obtained from computed tomography (CT) scans, but CT-guided stereotactic aspiration was required for diagnosis and treatment in every case. After Nocardia asteroides was seen on Gram's stain and subsequently identified by culture, appropriate antibiotic therapy was initiated. Both heart transplant patients survived in good neurological condition. We believe that stereotactic aspiration followed by prolonged antibiotic therapy may significantly improve the outcome of patients with nocardial brain abscess. KEY WORDS: Abscess surgery; Stereotactic treatment; Brain abscess; Nocardial infections; Computed tomography scanning
Nocardia, an aerobic gram-positive, filamentous, weakly
acid-fast bacterium, is a genus o f Actinomycetaceae [11,22]. The organism, a soil saphrophyte, was first recognized as a pathogen in cattle by Nocard in 1888 [21]. Two years later, Eppinger isolated the microbe from a brain abscess [9]. Blanchard named the organism N. asteroides in 1896 [3]. Krueger et al [16] reported the first case of successfully treated nocardial brain abscess in 1954. Although uncommon, cerebral nocardiosis has been documented in more than 50 patients [6,30]. Surgical drainage either by craniotomy with abscess capsule excision or by aspiration has been described [6,27].
Address reprint requests to: Walter A. Hall, M.D., Department of Neurosurgery, 9402 Presbyterian-UniversityHospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.
© 1987 by ElsevierSciencePublishingCo., Inc.
Medical management alone or in combination with surgical drainage has been reported in patients without underlying malignancies who were not immunosuppressed [6,26,31]. Patients with multiple intracerebral nocardial abscesses after organ transplantation have responded solely to chemotherapeutic agents [1,14]. We review the three cases of nocardial brain abscess seen at our institution since 1982. One patient had polyarteritis nodosa and the other patients were recent cardiac transplant recipients on immunosuppression. All three were treated with computed tomography (CT)-guided stereotactic aspiration and the appropriate antibiotic regimen.
Case Reports Case I
A 62-year-old man with polyarteritis nodosa, evaluated for 2 weeks of lethargy and right-sided weakness, had a CT scan which disclosed a left thalamic mass. H e was treated with prednisone and Cytoxan (Head Johnson & Co., Evansville, IN) for his vasculitis. On neurologic examination he was dysarthric, hemiparetic on the right, and had a right extensor plantar response. Five days after admission he underwent a CT-guided stereotactic biopsy and aspiration o f the left thalamic lesion. Gram's stain of the specimen disclosed polymorphonuclear leukocytes, histiocytes, and gram-positive filamentous branching organisms (Figure 1). The patient was treated with triple sulfonamides and N . asteroides was subsequently grown on Sabouraud's agar, blood agar, and AFB medium. On the third day following surgery, the patient had a decreasing level of consciousness, a dilated left pupil, and a right hemiplegia. After an emergency CT scan demonstrated blood in the abscess cavity, not present on the immediate postoperative scan, he underwent a craniotomy with drainage of the abscess and the hemorrhage. Aspiration pneumonia complicated the patient's course necessitating a tracheostomy and gastrostomy. H e re0090-3019/87/$3.50
Nocardial Brain Abscess
mained aphasic and hemiplegic despite continued antibiotic therapy and died 8 weeks later in an extended care facility.
Surg Neurol 1987;28:114-8
115
Figure 1. Case 1. Beaded, branching filamentous Nocardia asteroides seen uith Gram's stain ( × 500~.
Case 3 Case 2 A 56-year-old cardiac transplant recipient on cyclosporine and prednisone was evaluated for generalized weakness and pain of the left chest wall for 2 weeks. Physical examination showed a mass over the left eighth rib and a normal neurologic examination. T h e 3 × 4 cm mass was confirmed on chest x-ray and CT scan. The patient had a tonic-clonic seizure 2 days after admission and a CT scan revealed an enhancing left frontoparietal mass (Figure 2). Chest wall biopsy showed gram-positive bacteria which were identified as N. asteroides on culture. Intravenous trimethoprim-sulfamethoxazole was the primary therapeutic drug. Spinal fluid indices and cultures were unremarkable. Enlargement o f the intracerebral mass radiographically with d e v e l o p m e n t of hemiparesis p r o m p t e d a stereotactic biopsy and aspiration from which N. asteroides was cultured. Oral sulfisoxazole was started after 1 month of intravenous therapy and continued for 9 months until resolution of the abscess was demonstrated on followup CT scans.
A 41-year-old male orthotopic heart transplant recipient had two grand real seizures 2 days before admission. A right parietal lobe mass was seen on C T scan and a lumbar puncture was normal. T w o weeks before his seizures, the patient began having right u p p e r quadrant pain. Admission physical examination was notable for a left extensor plantar response and right abdominal wall tenderness. A C T scan of the a b d o m e n demonstrated a 5 cm hypodense collection in the musculus transversus abdominis on the right and a similar 4 cm collection in the left musculus iliocostalis l u m b o r u m (Figure 3). Biopsy specimens of these lesions showed branching, filamentous gram-positive bacilli which were found to be N. asteroides on culture and intravenous sulfisoxazole was started. After an increase in the size o f the parietal lesion on CT scan, a stereotactic biopsy and aspiration was performed. Nocardia asteroides was cultured from the specimen and the patient has been continued on oral sulfisoxazole with abscess resolution on C T scan at 7 months.
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Figure 2. Case 2. (A) CT scan before intravenous injection of contrast medium, showing the left frontoparietal mass. (B) Left frontoparietal mass seen on CT scan after the administration of contrast medium.
Figure 3. Case3. Abdominal CT scan revealing low attenuation collections in the right musculus transversus abdominis (A) and the left musculus iliocostalis lumborum (B), from which Nocardia asteroides was later cultured.
Discussion Nocardia infection is caused primarily by N . asteroides and N . brasiliensis, each with a characteristic disease pattern [11,24]. In systemic nocardiosis, caused by N . asteroides, a primary pulmonary focus is found in 7 5 % - 8 5 %
of cases [6,22]. Pulmonary involvement may be subclinical or severe, transitory or chronic. N o c a r d i a disseminates from the skin in 4 % of cases [22]. Hematogenous dissemination to the central nervous system
Nocardial Brain Abscess
(CNS) where abscess formation is common occurs in 2 0 % - 4 5 % of patients [12,16,27]. Primary nocardiosis of the brain is seen in 7% of the cases [2]. It is estimated that 5 0 0 - 1 0 0 0 new cases of nocardiosis are identified each year [2,8,22]. Thirty to seventy-five percent of these patients have underlying malignancies, immunodeficiency states, diabetes mellitus, collagen vascular disease, or iatrogenic immunosuppression following organ transplantation [2,22]. Those patients afflicted with the disease range in age from 20 to 65 years with a mean age of 45 years [2,11,22,24,30]. Men are affected three times as often as women [ 15,24]. Intracerebral nocardiosis presents clinically as a mass lesion due to poorly encapsulated abscess formation with focal signs and symptoms referable to the involved area of the brain. Many patients also have diffuse abnormalities including difficulty in mentation, headache, nausea and vomiting, dizziness, unsteadiness, and seizures [ 11]. Fever and an elevated white blood cell count may not be present, particularly in the presence of immunosuppression. Leptomeningitis is uncommon even with a known intracerebral abscess and cerebrospinal fluid will often be normal, as one of our cases illustrates [22]. A high index of clinical suspicion or a proven nocardial abscess in a peripheral location may help in the diagnosis of cerebral nocardiosis. Skin and serological tests have not been clinically useful. With pulmonary involvement, the chest film or thoracic CT scan may show infiltrates, cavities, or mass lesions. CT brain scanning has become the diagnostic test of choice for intracerebral mass lesions. Eighty percent of nocardial brain abscesses enhance after the intravenous administration of contrast medium [6,7]. The presence of multiple and multiloculated lesions, well demonstrated by CT, may direct treatment plans toward exclusively medical management [ 1,4,29]. CT scanning also provides a convenient way to monitor the patient's response to antimicrobial therapy after abscess evacuation. The mortality rate for intracerebral nocardiosis is between 75% and 90% [10,30]. A good prognosis has been related to four factors: (a) early diagnosis; (b) absence of underlying disease; (c) administration of appropriate chemotherapy; and (d) restricted disease [6]. Because o f the high relapse rate seen with this infection, prolonged antibiotic therapy is usually recommended [6,18,30]. Byrne et al [6] described a patient who suffered a relapse 1 year after discontinuing therapy. Sulfa drugs in high doses ( 6 - 1 2 g/day) are the mainstay of therapy [23,26]. The white blood cell count must be monitored closely in patients with immunosuppression on sulfa drugs. For those allergic to sulfa drugs or when sulfonamide-resistant strains are being treated, minocycline is an acceptable treatment alternative despite
Surg Neurol 1987;28:114-8
117
limited experience in treating CNS disease [31]. In cases with multiple intracerebral abscesses or where surgical drainage is not indicated except for diagnosis, antibiotic treatment alone has proven therapeutic [14]. Many neurosurgeons believe that surgical removal by aspiration or by open drainage is the mainstay of treatment [12,17,20]. Aspiration alone has been complicated by meningeal seeding with infection [28]. Stereotactic aspiration or open craniotomy is indicated for diagnosis or in patients with systemic nocardiosis on appropriate antibiotic therapy who worsen neurologically or show enlargement of their intracerebral lesions on CT scan. Whenever possible, immunosuppressive therapy should be discontinued or decreased even though neither cardiac transplant recipient had a reduction in their immunosuppression. In 1981, Britt et al [4] reviewed the intracranial infections seen in the first 182 cardiac transplant patients at Stanford University. Sixteen patients were found to have primarily either toxoplasmosis or aspergillosis brain abscesses. Intracerebral nocardiosis was not seen. An earlier evaluation of the Nocardia infections seen in the Stanford cardiac recipients found seven cases of pulmonary involvement without dissemination [15]. In over 240 cardiac transplant recipients at this institution, three patients developed nocardiosis and two of these had intracerebral disease. Autopsy cases reflect the other types of intracerebral infections seen in our cardiac transplant population [19]. The different types of immunosuppressive therapy used following cardiac transplantation may explain the inconsistent patterns of infection seen at both medical centers. In 16 nonimmunosuppressed patients with cerebral nocardiosis reported by Byrne et al [6], only one patient underwent surgical aspiration. Few reports of immunocompromised patients with intracerebral nocardiosis who successfully received antibiotics alone have been published [1,13]. We describe three patients with altered immunity who had CT-guided stereotactic aspiration of their intracerebral abscesses and subsequent antibiotic therapy. Two of our patients responded well to these therapeutic modalities. We believe that this preliminary evidence of improved survival rate, in contrast to the 75% mortality previously reported, occurs because of early diagnosis, prompt surgical aspiration, and prolonged intensive antibiotic therapy once a definite diagnosis is achieved [10].
The authors are indebted to Drs. Robert L. Hardesty, Bartley P. Griffith, and Alfredo Trento fi~rthe inclusion of their patients in this review.
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Surg N e u r o l 1987;28:114-8
References 1. Barmeir E, Mann JH, Marcus RH. Cerebral nocardiosis in renal transplant patients. Br J Radiol 1981;54:1107-9. 2. Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis 1976;134: 286-9. 3. Blanchard R. Parasites v~gCtaux a l'excursion des bactdries. In: Bouchard C, ed. Trait6 de pathologie gCnCrale. Paris: Masson, 1896:811-926. 4. Britt RH, Enzmann DR, Remington JS. Intracranial infection in cardiac transplant recipients. Ann Neurol 1981;9:107-19. 5. Burger PC, Vogel FS. Surgical pathology of the nervous system and its coverings. 2nd ed. New York:John Wiley and Sons, 1982: 180-3. 6. Byrne E, Brophy BP, Perrett LV. Nocardia cerebral abscess: new concepts in diagnosis, management, and prognosis. J Neurol Neurosurg Psychiatry 1979;42:1038-45. 7. Claveria LE, du Boulay GH, Moseley IF. Intracranial infections: investigation by computerized axial tomography. Neuroradiology 1976;12:59-71. 8. Curry WA. Human nocardiosis: a clinical review with selected case reports. Arch Intern Med 1980;140:818-26. 9. Eppinger H. Ueber eine neue, pathogene Cladothrix und eine durch sie hervorgerufene Pseudotuberculosis. Wien Kiln Wochenschr 1890;3:321-3. 10. Frazier AR, Rosenow EC, Roberts GD. Nocardiosis: a review of 25 cases during 24 months. Mayo Clin Proc 1975;50:657-63. 11. Hoeprich PD. Infectious disease. 3rd ed. Philadelphia: Harper & Row, 1983:419-27. 12. Jacobs SI, Gibson RM. A fatal case of cerebral abscess due to Nocardia asteroides. J Neurol Neurosurg Psychiatry 1963;26:363-7. 13. Khalili AH. Nocardial brain abscess: a case report. J Neurol 1982;227:115-20. 14. Kirmani N, Tuazon CU, OcuinJA, Thompson AM, Kramer NC, Geelhoed GW. Extensive cerebral nocardiosis cured with antibiotic therapy alone: case report. J Neurosurg 1978;49:924-8. 15. Krick JA, Stinson EB, Remington JS. Nocardia infection in heart transplant patients. Ann Intern Med 1975;82:18-26. 16. Krueger EG, Norsa L, Kenney M, Price PA. Nocardiosis of the central nervous system. J Neurosurg 1954;11:226-33.
Hall et al
17. List CF, Williams JF, Beeman CB, Payne CA. Nocardiosis with multilocular cerebellar abscess: report of a cured case. J Neurosurg 1954;11:394-8. 18. Mills VA, Cleary TG, Frankel L, Miner ME, Wallace RJ, SilvaSosa M. Central nervous system Nocardia infection. Clin Pediatr 1982;21: 248-50. 19. Montero CG, Martinez AJ. Neuropathological findings in heart transplants: a review of 23 consecutive cases. Neurology 1986;36: 1149-54. 20. Munslow RA. Actinomycotic (Nocardia asteroides) brain abscess with recovery: case report. J Neurosurg 1954;11:399-402. 21. Nocard ME. Note sur la maladie des boeufs de la Guadeloupe: Connue sous le nom de farcin. Ann Inst Pasteur Microbiol 1888;2: 293-302. 22. Palmer DL, Harvey RL, WheelerJK. Diagnostic and therapeutic considerations in Nocardia asteroides infection. Medicine 1974;53: 391-401. 23. Pavillard ER. Treatment of nocardial infection with trimethoprimsulfamethoxazole. Med J Aust 1973;1:65-9. 24. Rosenblum ML, Rosegay H. Resection of multiple nocardial brain abscesses: diagnostic role of computerized tomography. Neurosurgery 1979;4:315-8. 25. Scoravilli F. Parasitic and fungal infections of the nervous system. Adams JH, Corsellis JAN, Duchen LW, eds. Greenfield's neuropathology. New York: John Wiley and Sons, 1984:330-1. 26. Smego RA, Moeller MB, Gallis HA. Trimethoprim-sulfamethoxazole therapy for Nocardia infections. Arch Intern Med 1983;143:711-8. 27. Turner E, Whitby JL. Nocardial cerebral abscess with systemic involvement successfully treated with aspiration and sulphonamides. J Neurosurg 1969;31:227-9. 28. Turner OA. Brain abscess caused by Nocardia asteroides. J Neurosurg 1954;11:312-8. 29. Viroslav J, Williams TW. Nocardial infection of the pulmonary and central nervous system: successful treatment with medical therapy. S African Med J 1971;64:1382-5. 30. Weiss MH, Jane JA, Nocardia asteroides brain abscess successfully treated by enucleation: case report. J Neurosurg 1969;30:83-6. 31. Wren MV, Savage AM, Alford RH. Apparent cure ofintracranial Nocardia asteroides infection by minocycline. Arch Intern Med 1979;139:249-50.
Surg Neurol 1987;28:114-8
Nocardial Brain Abscess: Diagnostic and Therapeutic Use of Stereotactic Aspiration Walter A. Hall, M.D., A. Julio Martinez, M.D., J. Stephen Dummer, M.D., and L. Dade Lunsford, M.D. Departments of Neurosurgery, Neuropathology, Medicine and Neuroradiology, Hospitals of the University Health Center of Pittsburgh, Pittsburgh, Pennsylvania
Hall WA, Martinez AJ, Dummer JS, LunsfordLD. Nocardial brain abscess: diagnostic and therapeutic use of stereotactic aspiration. Surg Neurol 1987;28:114-8. Three cases of nocardial brain abscess are presented. All three patients were receiving immunosuppressive therapy at the time of diagnosis. Two patients had cardiac transplantation and the third had periarteritis nodosa. The patients presented with generalized seizures or focal weakness. Accurate localization of the intracerebral mass lesion was obtained from computed tomography (CT) scans, but CT-guided stereotactic aspiration was required for diagnosis and treatment in every case. After Nocardia asteroides was seen on Gram's stain and subsequently identified by culture, appropriate antibiotic therapy was initiated. Both heart transplant patients survived in good neurological condition. We believe that stereotactic aspiration followed by prolonged antibiotic therapy may significantly improve the outcome of patients with nocardial brain abscess. KEY WORDS: Abscess surgery; Stereotactic treatment; Brain abscess; Nocardial infections; Computed tomography scanning
Nocardia, an aerobic gram-positive, filamentous, weakly
acid-fast bacterium, is a genus o f Actinomycetaceae [11,22]. The organism, a soil saphrophyte, was first recognized as a pathogen in cattle by Nocard in 1888 [21]. Two years later, Eppinger isolated the microbe from a brain abscess [9]. Blanchard named the organism N. asteroides in 1896 [3]. Krueger et al [16] reported the first case of successfully treated nocardial brain abscess in 1954. Although uncommon, cerebral nocardiosis has been documented in more than 50 patients [6,30]. Surgical drainage either by craniotomy with abscess capsule excision or by aspiration has been described [6,27].
Address reprint requests to: Walter A. Hall, M.D., Department of Neurosurgery, 9402 Presbyterian-UniversityHospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.
© 1987 by ElsevierSciencePublishingCo., Inc.
Medical management alone or in combination with surgical drainage has been reported in patients without underlying malignancies who were not immunosuppressed [6,26,31]. Patients with multiple intracerebral nocardial abscesses after organ transplantation have responded solely to chemotherapeutic agents [1,14]. We review the three cases of nocardial brain abscess seen at our institution since 1982. One patient had polyarteritis nodosa and the other patients were recent cardiac transplant recipients on immunosuppression. All three were treated with computed tomography (CT)-guided stereotactic aspiration and the appropriate antibiotic regimen.
Case Reports Case I
A 62-year-old man with polyarteritis nodosa, evaluated for 2 weeks of lethargy and right-sided weakness, had a CT scan which disclosed a left thalamic mass. H e was treated with prednisone and Cytoxan (Head Johnson & Co., Evansville, IN) for his vasculitis. On neurologic examination he was dysarthric, hemiparetic on the right, and had a right extensor plantar response. Five days after admission he underwent a CT-guided stereotactic biopsy and aspiration o f the left thalamic lesion. Gram's stain of the specimen disclosed polymorphonuclear leukocytes, histiocytes, and gram-positive filamentous branching organisms (Figure 1). The patient was treated with triple sulfonamides and N . asteroides was subsequently grown on Sabouraud's agar, blood agar, and AFB medium. On the third day following surgery, the patient had a decreasing level of consciousness, a dilated left pupil, and a right hemiplegia. After an emergency CT scan demonstrated blood in the abscess cavity, not present on the immediate postoperative scan, he underwent a craniotomy with drainage of the abscess and the hemorrhage. Aspiration pneumonia complicated the patient's course necessitating a tracheostomy and gastrostomy. H e re0090-3019/87/$3.50
Nocardial Brain Abscess
mained aphasic and hemiplegic despite continued antibiotic therapy and died 8 weeks later in an extended care facility.
Surg Neurol 1987;28:114-8
115
Figure 1. Case 1. Beaded, branching filamentous Nocardia asteroides seen uith Gram's stain ( × 500~.
Case 3 Case 2 A 56-year-old cardiac transplant recipient on cyclosporine and prednisone was evaluated for generalized weakness and pain of the left chest wall for 2 weeks. Physical examination showed a mass over the left eighth rib and a normal neurologic examination. T h e 3 × 4 cm mass was confirmed on chest x-ray and CT scan. The patient had a tonic-clonic seizure 2 days after admission and a CT scan revealed an enhancing left frontoparietal mass (Figure 2). Chest wall biopsy showed gram-positive bacteria which were identified as N. asteroides on culture. Intravenous trimethoprim-sulfamethoxazole was the primary therapeutic drug. Spinal fluid indices and cultures were unremarkable. Enlargement o f the intracerebral mass radiographically with d e v e l o p m e n t of hemiparesis p r o m p t e d a stereotactic biopsy and aspiration from which N. asteroides was cultured. Oral sulfisoxazole was started after 1 month of intravenous therapy and continued for 9 months until resolution of the abscess was demonstrated on followup CT scans.
A 41-year-old male orthotopic heart transplant recipient had two grand real seizures 2 days before admission. A right parietal lobe mass was seen on C T scan and a lumbar puncture was normal. T w o weeks before his seizures, the patient began having right u p p e r quadrant pain. Admission physical examination was notable for a left extensor plantar response and right abdominal wall tenderness. A C T scan of the a b d o m e n demonstrated a 5 cm hypodense collection in the musculus transversus abdominis on the right and a similar 4 cm collection in the left musculus iliocostalis l u m b o r u m (Figure 3). Biopsy specimens of these lesions showed branching, filamentous gram-positive bacilli which were found to be N. asteroides on culture and intravenous sulfisoxazole was started. After an increase in the size o f the parietal lesion on CT scan, a stereotactic biopsy and aspiration was performed. Nocardia asteroides was cultured from the specimen and the patient has been continued on oral sulfisoxazole with abscess resolution on C T scan at 7 months.
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Figure 2. Case 2. (A) CT scan before intravenous injection of contrast medium, showing the left frontoparietal mass. (B) Left frontoparietal mass seen on CT scan after the administration of contrast medium.
Figure 3. Case3. Abdominal CT scan revealing low attenuation collections in the right musculus transversus abdominis (A) and the left musculus iliocostalis lumborum (B), from which Nocardia asteroides was later cultured.
Discussion Nocardia infection is caused primarily by N . asteroides and N . brasiliensis, each with a characteristic disease pattern [11,24]. In systemic nocardiosis, caused by N . asteroides, a primary pulmonary focus is found in 7 5 % - 8 5 %
of cases [6,22]. Pulmonary involvement may be subclinical or severe, transitory or chronic. N o c a r d i a disseminates from the skin in 4 % of cases [22]. Hematogenous dissemination to the central nervous system
Nocardial Brain Abscess
(CNS) where abscess formation is common occurs in 2 0 % - 4 5 % of patients [12,16,27]. Primary nocardiosis of the brain is seen in 7% of the cases [2]. It is estimated that 5 0 0 - 1 0 0 0 new cases of nocardiosis are identified each year [2,8,22]. Thirty to seventy-five percent of these patients have underlying malignancies, immunodeficiency states, diabetes mellitus, collagen vascular disease, or iatrogenic immunosuppression following organ transplantation [2,22]. Those patients afflicted with the disease range in age from 20 to 65 years with a mean age of 45 years [2,11,22,24,30]. Men are affected three times as often as women [ 15,24]. Intracerebral nocardiosis presents clinically as a mass lesion due to poorly encapsulated abscess formation with focal signs and symptoms referable to the involved area of the brain. Many patients also have diffuse abnormalities including difficulty in mentation, headache, nausea and vomiting, dizziness, unsteadiness, and seizures [ 11]. Fever and an elevated white blood cell count may not be present, particularly in the presence of immunosuppression. Leptomeningitis is uncommon even with a known intracerebral abscess and cerebrospinal fluid will often be normal, as one of our cases illustrates [22]. A high index of clinical suspicion or a proven nocardial abscess in a peripheral location may help in the diagnosis of cerebral nocardiosis. Skin and serological tests have not been clinically useful. With pulmonary involvement, the chest film or thoracic CT scan may show infiltrates, cavities, or mass lesions. CT brain scanning has become the diagnostic test of choice for intracerebral mass lesions. Eighty percent of nocardial brain abscesses enhance after the intravenous administration of contrast medium [6,7]. The presence of multiple and multiloculated lesions, well demonstrated by CT, may direct treatment plans toward exclusively medical management [ 1,4,29]. CT scanning also provides a convenient way to monitor the patient's response to antimicrobial therapy after abscess evacuation. The mortality rate for intracerebral nocardiosis is between 75% and 90% [10,30]. A good prognosis has been related to four factors: (a) early diagnosis; (b) absence of underlying disease; (c) administration of appropriate chemotherapy; and (d) restricted disease [6]. Because o f the high relapse rate seen with this infection, prolonged antibiotic therapy is usually recommended [6,18,30]. Byrne et al [6] described a patient who suffered a relapse 1 year after discontinuing therapy. Sulfa drugs in high doses ( 6 - 1 2 g/day) are the mainstay of therapy [23,26]. The white blood cell count must be monitored closely in patients with immunosuppression on sulfa drugs. For those allergic to sulfa drugs or when sulfonamide-resistant strains are being treated, minocycline is an acceptable treatment alternative despite
Surg Neurol 1987;28:114-8
117
limited experience in treating CNS disease [31]. In cases with multiple intracerebral abscesses or where surgical drainage is not indicated except for diagnosis, antibiotic treatment alone has proven therapeutic [14]. Many neurosurgeons believe that surgical removal by aspiration or by open drainage is the mainstay of treatment [12,17,20]. Aspiration alone has been complicated by meningeal seeding with infection [28]. Stereotactic aspiration or open craniotomy is indicated for diagnosis or in patients with systemic nocardiosis on appropriate antibiotic therapy who worsen neurologically or show enlargement of their intracerebral lesions on CT scan. Whenever possible, immunosuppressive therapy should be discontinued or decreased even though neither cardiac transplant recipient had a reduction in their immunosuppression. In 1981, Britt et al [4] reviewed the intracranial infections seen in the first 182 cardiac transplant patients at Stanford University. Sixteen patients were found to have primarily either toxoplasmosis or aspergillosis brain abscesses. Intracerebral nocardiosis was not seen. An earlier evaluation of the Nocardia infections seen in the Stanford cardiac recipients found seven cases of pulmonary involvement without dissemination [15]. In over 240 cardiac transplant recipients at this institution, three patients developed nocardiosis and two of these had intracerebral disease. Autopsy cases reflect the other types of intracerebral infections seen in our cardiac transplant population [19]. The different types of immunosuppressive therapy used following cardiac transplantation may explain the inconsistent patterns of infection seen at both medical centers. In 16 nonimmunosuppressed patients with cerebral nocardiosis reported by Byrne et al [6], only one patient underwent surgical aspiration. Few reports of immunocompromised patients with intracerebral nocardiosis who successfully received antibiotics alone have been published [1,13]. We describe three patients with altered immunity who had CT-guided stereotactic aspiration of their intracerebral abscesses and subsequent antibiotic therapy. Two of our patients responded well to these therapeutic modalities. We believe that this preliminary evidence of improved survival rate, in contrast to the 75% mortality previously reported, occurs because of early diagnosis, prompt surgical aspiration, and prolonged intensive antibiotic therapy once a definite diagnosis is achieved [10].
The authors are indebted to Drs. Robert L. Hardesty, Bartley P. Griffith, and Alfredo Trento fi~rthe inclusion of their patients in this review.
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Surg N e u r o l 1987;28:114-8
References 1. Barmeir E, Mann JH, Marcus RH. Cerebral nocardiosis in renal transplant patients. Br J Radiol 1981;54:1107-9. 2. Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis 1976;134: 286-9. 3. Blanchard R. Parasites v~gCtaux a l'excursion des bactdries. In: Bouchard C, ed. Trait6 de pathologie gCnCrale. Paris: Masson, 1896:811-926. 4. Britt RH, Enzmann DR, Remington JS. Intracranial infection in cardiac transplant recipients. Ann Neurol 1981;9:107-19. 5. Burger PC, Vogel FS. Surgical pathology of the nervous system and its coverings. 2nd ed. New York:John Wiley and Sons, 1982: 180-3. 6. Byrne E, Brophy BP, Perrett LV. Nocardia cerebral abscess: new concepts in diagnosis, management, and prognosis. J Neurol Neurosurg Psychiatry 1979;42:1038-45. 7. Claveria LE, du Boulay GH, Moseley IF. Intracranial infections: investigation by computerized axial tomography. Neuroradiology 1976;12:59-71. 8. Curry WA. Human nocardiosis: a clinical review with selected case reports. Arch Intern Med 1980;140:818-26. 9. Eppinger H. Ueber eine neue, pathogene Cladothrix und eine durch sie hervorgerufene Pseudotuberculosis. Wien Kiln Wochenschr 1890;3:321-3. 10. Frazier AR, Rosenow EC, Roberts GD. Nocardiosis: a review of 25 cases during 24 months. Mayo Clin Proc 1975;50:657-63. 11. Hoeprich PD. Infectious disease. 3rd ed. Philadelphia: Harper & Row, 1983:419-27. 12. Jacobs SI, Gibson RM. A fatal case of cerebral abscess due to Nocardia asteroides. J Neurol Neurosurg Psychiatry 1963;26:363-7. 13. Khalili AH. Nocardial brain abscess: a case report. J Neurol 1982;227:115-20. 14. Kirmani N, Tuazon CU, OcuinJA, Thompson AM, Kramer NC, Geelhoed GW. Extensive cerebral nocardiosis cured with antibiotic therapy alone: case report. J Neurosurg 1978;49:924-8. 15. Krick JA, Stinson EB, Remington JS. Nocardia infection in heart transplant patients. Ann Intern Med 1975;82:18-26. 16. Krueger EG, Norsa L, Kenney M, Price PA. Nocardiosis of the central nervous system. J Neurosurg 1954;11:226-33.
Hall et al
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