Nocardia abscess during treatment of brain toxoplasmosis in a patient with aids, utility of proton MR spectroscopy and diffusion-weighted imaging in diagnosis.
We report the case of a 30-year-old man with known HIV-positive status who developed, 4 months prior to admission, recurrent left partial motor seizures followed by left hemiparesis. At another hospital, contrasted CT scan of the head revealed right frontal hypodense lesion with mass effect and focal contrast enhancement. A small left occipital lesion was also present. HIV-associated brain toxoplasmosis was considered and phenytoin, pyrimethamine, clindamycin and antiretrovirals were administered. Hemiparesis improved but, 3 weeks prior to admission, he developed progressive headache and bilateral visual defects. Upon admission to our center, he was found with left homonymous hemianopsia, right hemiparesis and a large hypodense left occipital lesion on a head CT scan. Proton MR spectroscopy showed lactate at 1.3ppm, amino acids at 0.9ppm, and diffusion-weighted imaging (DWI) revealed hyperintensity at the lesion, suggesting a pyogenic abscess. Aspiration yielded purulent material and Nocardia asteroides grew in culture. The patient was treated with trimethoprim-sulfametoxazole and recovered with a mild visual field residual defect.
Soto-Hernández
José Luis
JL
Department of Infectious Diseases, Instituto Nacional de Neurología y Neurocirugía, Manuel Velasco Suárez, Insurgentes Sur 3877, Tlalpan, 14269 México, D.F., Mexico. joseluis_sotohernandez@yahoo.com
Moreno-Andrade
Talía
T
Góngora-Rivera
Fernando
F
Ramírez-Crescencio
María Antonieta
MA
D000163:Acquired Immunodeficiency Syndrome / Q000150:complications* / Q000188:drug therapy; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use; D000981:Antiprotozoal Agents / Q000627:therapeutic use; D001922:Brain Abscess / Q000150:complications / Q000382:microbiology / Q000473:pathology; D002981:Clindamycin / Q000627:therapeutic use; D038524:Diffusion Magnetic Resonance Imaging; D004359:Drug Therapy, Combination; D006801:Humans; D009682:Magnetic Resonance Spectroscopy; D008297:Male; D009617:Nocardia Infections / Q000150:complications / Q000382:microbiology / Q000473:pathology; D009616:Nocardia asteroides / Q000302:isolation & purification; D010672:Phenytoin / Q000627:therapeutic use; D011522:Protons; D011739:Pyrimethamine / Q000627:therapeutic use; D016781:Toxoplasmosis, Cerebral / Q000150:complications* / Q000188:drug therapy*
D000900:Anti-Bacterial Agents; D044966:Anti-Retroviral Agents; D000927:Anticonvulsants; D000981:Antiprotozoal Agents; D011522:Protons; D002981:Clindamycin; D010672:Phenytoin; D011739:Pyrimethamine