Neurosurgical management of multiple intracranial Nocardia and Enterococcus abscesses in an immunocompetent patient

Neurosurgical management of multiple intracranial Nocardia and Enterococcus abscesses in an... Nocardia farcinica and Enterococcus faecium are both rare causes of cerebral abscess. The former is associated with high mor- bidity and mortality. We describe a neurosurgical approach to the management of multiple intracranial abscesses of dual microbial pathology in an immunocompetent patient to achieve a good outcome. INTRODUCTION chronic hyponatraemia. There was no history of immunocom- Nocardia species account for ~2% of all cerebral abscesses [1]. promise however he was malnourished. Of note, there was no history of foreign travel, intravenous drug use or household This most often presents following opportunistic infection of an immunosuppressed patient. Cerebral abscess formation in pets however the patient had undergone four dental fillings in the preceding 12 months. Neurological examination indicated the immunocompetent patient is therefore less well-described. Cerebral abscesses of an Enterococcus aetiology are similarly MRC grade 2/5 power throughout the left upper and lower limbs with increased tone. The patient was apyrexic with a CRP of rare and predisposing factors are often found. The largest case series numbers 12 patients with only 10 cases identified in the 68 mg/L. A CT brain revealed a right frontal mass lesion with sur- preceding literature [2]. The rarity of these cases and lack of rounding oedema which was concerning for malignancy when prospective, randomized data means the optimum therapeutic taken in conjunction with the weight loss. Investigations for strategy is often unclear. This case report presents the clinical course and management of a patient with five supra-tentorial a primary tumour were negative including a CT of the chest, abdomen and pelvis in addition to upper GI endoscopy. Tumour abscesses requiring multiple neurosurgical procedures. No other markers did not reveal any abnormality. Additional testing for cases have been identified in the literature which describe co- immunocompromise including HIV was negative and no pri- existent Nocardia and Enterococcus abscesses in an immunocom- petent patient. mary source of infection was identified. A subsequent MRI brain revealed a total of five ring-enhancing lesions with vasogenic oedema distributed throughout both cerebral hemispheres with CASE REPORT the largest measuring >2 cm (Fig. 1). A 53-year-old male presented with a gradual onset of left-sided Commencement of dexamethasone (8 mg twice-daily) ini- hemiplegia and weight loss of 14 kg over a period of ~4 weeks. tially resulted in a good clinical response. Image-guided exci- His past medical history included COPD, hypertension and sion of the right frontal abscess was undertaken and culture Received: November 14, 2017. Accepted: January 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 D.N. Holmes et al. Figure 2: Post-contrast axial T1-weighted MRI following resection of abscesses in the right frontal lobe (a, b), left insular region (b) and left occipital lobe (b). subsequent haematogenous spread. It is a particularly chal- lenging infection to diagnose and treat as it may sometimes appear Gram-negative while prolonged culture time may result in masking by faster-growing, non-pathological organ- isms. Furthermore, resistance to empirical anti-microbial therapy for cerebral abscess including cephalosporins is com- mon. Nocardia asteroides has previously been recognized as Figure 1: Initial post-contrast T1-weighted MRI demonstrating three lesions the most common Nocardia species causing brain abscesses involving the right frontal lobe (a, b, c) with another in the left lateral occipital in a large case series [1]. However, more recent case reports lobe (d) and one in the left insular region (d). The lesions also displayed com- suggest N. farcinica is increasingly identified in this setting plex walls typical of an abscess capsule on T2-weighted imaging and demon- [3]. Unlike the case described in this report, these often relate strated central diffusion restriction (not shown). to immunocompromised individuals. Enterococcus species are Gram-positive cocci and the majority of reported intracranial results identified Nocardia farcinica. Despite appropriate treat- abscesses involve E. avium rather than E. faecium.Clinical out- ment with intravenous linezolid combined with imipenem and comes are more favourable when compared to those with Nocardia the subsequent addition of co-trimoxazole, repeat imaging abscesses [2]. A case of co-existing intracranial infection has not demonstrated a continued increase in size of the remaining previously been reported. abscesses. Two further operations were performed over a 4- The multiplicity of the abscesses, bilateral cerebral hemi- week period in addition to ongoing anti-microbial therapy. sphere involvement and absence of an identifiable site of pri- Resection of all abscesses was achieved through right frontal, mary infection are interesting aspects of this case which differ right parietal, left parieto-occipital and left temporal cranioto- from previously reported cases of N. farcinica in the literature. mies. Microbiological analysis identified Enterococcus faecium in These features also posed a challenge for surgical manage- a second abscess and vancomycin was added to the antibiotic ment. It has been demonstrated that patients with multiple regimen. Post-operative imaging indicated complete resection Nocardia abscesses have an observed mortality of 66% in com- and appearances were monitored with regular imaging (Fig. 2). parison to 33% for those with a single abscess [1]. This suggests A prolonged course of dexamethasone was required to main- that early recognition of lesions with prompt identification of tain neurological function. This may have contributed to a the underlying organism is of particular importance in this sub- wound dehiscence requiring an uneventful wash-out and group to facilitate early surgical intervention and anti-microbial repeat closure in theatre. Ongoing seizure activity was con- therapy tailored to sensitivities. Furthermore, progression of trolled with anticonvulsants. abscess formation despite anti-microbial therapy should prompt Due to fluctuating symptoms, the patient remained in hos- consideration of a second, co-existing microbial aetiology. The pital for the duration of intravenous antibiotics over a 4-month approach undertaken here to achieve a good outcome with no period. Oral ciprofloxacin (750 mg twice-daily) was commenced morbidity supports previously published recommendations for one year on discharge in addition to a 2-week course of oral endorsing aspiration of large abscesses with subsequent surgical Linezolid (600 mg twice-daily). Despite early post-operative excision if continued growth occurs following 2 weeks of anti- expressive dysphasia and slow resolution of left-sided weak- biotic therapy [1]. ness, there were no neurological deficits noted on discharge. In conclusion, this case report describes the successful Following in-patient rehabilitation, the patient was discharged treatment of multiple intracranial abscesses of dual anti- to his own home. A follow-up MRI at 6 months from discharge microbial pathology with surgical excision and appropriate has shown no evidence of disease recurrence. anti-microbial therapy to achieve a good functional outcome. It adds to the available literature regarding the management of Nocardia cerebral abscesses and is the first description of co- DISCUSSION existing intracranial E. faecium infection. This will be of import- Nocardia is a Gram-positive, aerobic, Actinomycete bacteria ance in assisting recognition of this rare condition and to found in soil which is acquired primarily by inhalation with inform treatment strategies. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Neurosurgical management of multiple intracranial Nocardia and Enterococcus abscesses 3 factors influencing outcome. Br J Neurosurg 1991;35: CONFLICT OF INTEREST STATEMENT 622–31. None declared. 2. Maiti TK, Nagarathna S, Kumari HBV, Shukla DP. A series of enterococcal brain abscesses. J Neurosci Rural Pract 2015;6:434–7. 3. Galacho-Harriero A, Delgado-López PD, Ortega-Lafont MP, REFERENCES Martín-Alonso J, Castilla-Díez JM, Sánchez-Borge B. Nocardia farcinica brain abscess: report of 3 cases. World Neurosurg 1. Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: treatment strategies and 2017;106:1053.e15–1053.e24. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Neurosurgical management of multiple intracranial Nocardia and Enterococcus abscesses in an immunocompetent patient

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Nocardia farcinica and Enterococcus faecium are both rare causes of cerebral abscess. The former is associated with high mor- bidity and mortality. We describe a neurosurgical approach to the management of multiple intracranial abscesses of dual microbial pathology in an immunocompetent patient to achieve a good outcome. INTRODUCTION chronic hyponatraemia. There was no history of immunocom- Nocardia species account for ~2% of all cerebral abscesses [1]. promise however he was malnourished. Of note, there was no history of foreign travel, intravenous drug use or household This most often presents following opportunistic infection of an immunosuppressed patient. Cerebral abscess formation in pets however the patient had undergone four dental fillings in the preceding 12 months. Neurological examination indicated the immunocompetent patient is therefore less well-described. Cerebral abscesses of an Enterococcus aetiology are similarly MRC grade 2/5 power throughout the left upper and lower limbs with increased tone. The patient was apyrexic with a CRP of rare and predisposing factors are often found. The largest case series numbers 12 patients with only 10 cases identified in the 68 mg/L. A CT brain revealed a right frontal mass lesion with sur- preceding literature [2]. The rarity of these cases and lack of rounding oedema which was concerning for malignancy when prospective, randomized data means the optimum therapeutic taken in conjunction with the weight loss. Investigations for strategy is often unclear. This case report presents the clinical course and management of a patient with five supra-tentorial a primary tumour were negative including a CT of the chest, abdomen and pelvis in addition to upper GI endoscopy. Tumour abscesses requiring multiple neurosurgical procedures. No other markers did not reveal any abnormality. Additional testing for cases have been identified in the literature which describe co- immunocompromise including HIV was negative and no pri- existent Nocardia and Enterococcus abscesses in an immunocom- petent patient. mary source of infection was identified. A subsequent MRI brain revealed a total of five ring-enhancing lesions with vasogenic oedema distributed throughout both cerebral hemispheres with CASE REPORT the largest measuring >2 cm (Fig. 1). A 53-year-old male presented with a gradual onset of left-sided Commencement of dexamethasone (8 mg twice-daily) ini- hemiplegia and weight loss of 14 kg over a period of ~4 weeks. tially resulted in a good clinical response. Image-guided exci- His past medical history included COPD, hypertension and sion of the right frontal abscess was undertaken and culture Received: November 14, 2017. Accepted: January 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 D.N. Holmes et al. Figure 2: Post-contrast axial T1-weighted MRI following resection of abscesses in the right frontal lobe (a, b), left insular region (b) and left occipital lobe (b). subsequent haematogenous spread. It is a particularly chal- lenging infection to diagnose and treat as it may sometimes appear Gram-negative while prolonged culture time may result in masking by faster-growing, non-pathological organ- isms. Furthermore, resistance to empirical anti-microbial therapy for cerebral abscess including cephalosporins is com- mon. Nocardia asteroides has previously been recognized as Figure 1: Initial post-contrast T1-weighted MRI demonstrating three lesions the most common Nocardia species causing brain abscesses involving the right frontal lobe (a, b, c) with another in the left lateral occipital in a large case series [1]. However, more recent case reports lobe (d) and one in the left insular region (d). The lesions also displayed com- suggest N. farcinica is increasingly identified in this setting plex walls typical of an abscess capsule on T2-weighted imaging and demon- [3]. Unlike the case described in this report, these often relate strated central diffusion restriction (not shown). to immunocompromised individuals. Enterococcus species are Gram-positive cocci and the majority of reported intracranial results identified Nocardia farcinica. Despite appropriate treat- abscesses involve E. avium rather than E. faecium.Clinical out- ment with intravenous linezolid combined with imipenem and comes are more favourable when compared to those with Nocardia the subsequent addition of co-trimoxazole, repeat imaging abscesses [2]. A case of co-existing intracranial infection has not demonstrated a continued increase in size of the remaining previously been reported. abscesses. Two further operations were performed over a 4- The multiplicity of the abscesses, bilateral cerebral hemi- week period in addition to ongoing anti-microbial therapy. sphere involvement and absence of an identifiable site of pri- Resection of all abscesses was achieved through right frontal, mary infection are interesting aspects of this case which differ right parietal, left parieto-occipital and left temporal cranioto- from previously reported cases of N. farcinica in the literature. mies. Microbiological analysis identified Enterococcus faecium in These features also posed a challenge for surgical manage- a second abscess and vancomycin was added to the antibiotic ment. It has been demonstrated that patients with multiple regimen. Post-operative imaging indicated complete resection Nocardia abscesses have an observed mortality of 66% in com- and appearances were monitored with regular imaging (Fig. 2). parison to 33% for those with a single abscess [1]. This suggests A prolonged course of dexamethasone was required to main- that early recognition of lesions with prompt identification of tain neurological function. This may have contributed to a the underlying organism is of particular importance in this sub- wound dehiscence requiring an uneventful wash-out and group to facilitate early surgical intervention and anti-microbial repeat closure in theatre. Ongoing seizure activity was con- therapy tailored to sensitivities. Furthermore, progression of trolled with anticonvulsants. abscess formation despite anti-microbial therapy should prompt Due to fluctuating symptoms, the patient remained in hos- consideration of a second, co-existing microbial aetiology. The pital for the duration of intravenous antibiotics over a 4-month approach undertaken here to achieve a good outcome with no period. Oral ciprofloxacin (750 mg twice-daily) was commenced morbidity supports previously published recommendations for one year on discharge in addition to a 2-week course of oral endorsing aspiration of large abscesses with subsequent surgical Linezolid (600 mg twice-daily). Despite early post-operative excision if continued growth occurs following 2 weeks of anti- expressive dysphasia and slow resolution of left-sided weak- biotic therapy [1]. ness, there were no neurological deficits noted on discharge. In conclusion, this case report describes the successful Following in-patient rehabilitation, the patient was discharged treatment of multiple intracranial abscesses of dual anti- to his own home. A follow-up MRI at 6 months from discharge microbial pathology with surgical excision and appropriate has shown no evidence of disease recurrence. anti-microbial therapy to achieve a good functional outcome. It adds to the available literature regarding the management of Nocardia cerebral abscesses and is the first description of co- DISCUSSION existing intracranial E. faecium infection. This will be of import- Nocardia is a Gram-positive, aerobic, Actinomycete bacteria ance in assisting recognition of this rare condition and to found in soil which is acquired primarily by inhalation with inform treatment strategies. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Neurosurgical management of multiple intracranial Nocardia and Enterococcus abscesses 3 factors influencing outcome. Br J Neurosurg 1991;35: CONFLICT OF INTEREST STATEMENT 622–31. None declared. 2. Maiti TK, Nagarathna S, Kumari HBV, Shukla DP. A series of enterococcal brain abscesses. J Neurosci Rural Pract 2015;6:434–7. 3. Galacho-Harriero A, Delgado-López PD, Ortega-Lafont MP, REFERENCES Martín-Alonso J, Castilla-Díez JM, Sánchez-Borge B. Nocardia farcinica brain abscess: report of 3 cases. World Neurosurg 1. Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: treatment strategies and 2017;106:1053.e15–1053.e24. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy015/4859681 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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