Disseminated CNS Nocardiosis: NEJM case report
A 55-year-old man presented with a two-day history of headache, fever, and generalized weakness. He had received a cadaveric kidney transplant five years earlier. His medications included 5 mg of tacrolimus twice a day and 10 mg of prednisone daily.

On neurologic examination, he was confused and incoherent. Cranial nerves were normal, but he had a hazy left retina. Strength examination showed an inability to overcome minimal resistance, more prominent on the right side. Deep tendon reflexes were exaggerated. Magnetic resonance imaging of the brain with the administration of gadolinium showed multiple enhancing lesions in both cerebral hemispheres (Panels A and B).

Examination of cerebrospinal fluid showed 1500 nucleated cells per cubic millimeter, with 84 percent neutrophils; a protein level of 227 mg per deciliter; and a glucose level of 41 mg per deciliter (2.3 mmol per liter). There was endophthalmitis of the left eye; a subretinal abscess was drained. Staining of the aspirate for acid-fast bacilli showed weakly positive organisms, suggestive of nocardia (Panel C).

Cultures grew Nocardia asteroides. The patient was treated with trimethoprim–sulfamethoxazole. Follow-up magnetic resonance imaging five weeks later showed that the abnormalities had diminished. One year of treatment with trimethoprim–sulfamethoxazole led to complete resolution of symptoms.

Source: https://www.nejm.org/doi/full/10.1056/NEJMicm990952
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