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Proceedings SNO “Percorsi clinici in Neuroscienze”
Case report IV SESSIONE
“LESIONI FOCALI INGANNEVOLI”
Multiple brain abscesses
due to disseminated Nocardiosis
in a immunosuppressed renal transplant patient
A. CASCIO RIZZO*, C. REGNA-GLADIN**, E.C. AGOSTONI**
* Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano “Niguarda”, Milan, Italy
** Neuroradiology, ASST Grande Ospedale Metropolitano “Niguarda”, Milan, Italy
INTRODUCTION rhythmic movements on the left side, lasting several
seconds, consistent with a focal seizure. Carbama-
A 75-year-old woman presented to the emergency de- zepine and antiplatelet therapy with acetilsalcylic
partment because of acute onset of weakness in her acid was started. She was admitted to our Stroke Unit
left arm at night. She was on immunosuppressive for further management. Laboratory tests were re-
therapy with cyclosporine and mycophenolate Mo- markable for high C-reactive protein (14 mg/L, nor-
fetil* because of bilateral kidney transplant a few mal value < 1.0), procalcitonine (2.7 ng/mL, normal
years earlier. Her medical history was also relevant value < 0.5) and creatinine (2 mg/dL). In the suspi-
for paroxysmal atrial fibrillation, chronic kidney dis- cion of cerebral septic emboli due to an infective en-
ease and diabetes mellitus. She had a history of re- docarditis, empiric antibiotic therapy with Ceftria-
lapsing fever in the past few weeks. On arrival the xone and Vancomicine was started. However both
temperature was 36 °C, the blood pressure 150/60 blood cultures and transthoracic echocardiography
mmHg, the heart rate 85 beats per minute and the were negative. Total body CT scan revealed multiple
oxygen saturation 99% while the patient was breath- pseudonodular lesions in the lung and subcutaneous
ing ambient air. Neurological examination revealed tissue of the chest and abdomen. Other similar lesions
mild disorientation in space and time, left gaze re- were found in the restrosternal and retroperitoneal ar-
striction with left hemianopia and facial droop, eas. Brain MRI showed multiple T2-weighted hyper-
tongue deviation, left arm pronator drift with weak intense nodular lesions in bilateral occipital and
grip-hand and mild left hemisensory loss. At general frontal lobes, with surrounding edema, DWI restric-
examination some purulent skin lesions in the chest, tion and ring enhancement (Figure 1) suspected to be
shoulder and sacral area were also found. CT of the multiple brain abscesses. Standard cultures of subcu-
head showed multiple focal hypodense lesions in bi- taneous lesions indicated a Nocardia Farcinica infec-
lateral occipital lobes (with patchy hyperdensity in tion and the final diagnosis of disseminated nocardio-
the right lesion), left parietal lobe and right rolandic sis was made. The patient then received specific an-
region with mild surrounding edema. During medical tibiotic therapy with oral sulfamethoxazole and intra-
observation she had an episode of hemifacial and arm venous imipenem. In addition mycophenolate mofetil
Corrispondenza: Dr. Angelo Cascio Rizzo, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, piazza
dell’Ospedale Maggiore 3, 20162 Milano (MI), tel. +39-(0)2-64442348, e-mail: angelo.casciorizzo@ospedaleniguarda.it
Percorsi clinici in Neuroscienze. Clinical Round SIN e SNO Lombardia, 21 gennaio 2022, Desio (Monza e Brianza)
Atti a cura di Paolo Ferroli, Alessandra Protti, Andrea Salmaggi, Ignazio Michele Santilli, Luca Valvassori
Copyright © 2022 by new Magazine edizioni s.r.l., Trento, Italia. www.newmagazine.it ISBN: 978-88-8041-135-2
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