CNS NOCARDIOSIS IN AIDS PATIENT V Jaber MD 1 , L Ledet MD2, V Burke MD 2 1 Department of Internal Medicine, LSU Health, New Orleans, LA 2 Department of Medicine, Section of Infectious Disease, LSU Health, New Orleans, LA
INTRODUCTION: Nocardia is frequently an opportunistic pathogen, occurring in patients with depressed cell-mediated immunity such as those with lymphoma, other selected malignancies, human immunodeficiency virus infection, solid-organ or hematopoietic stem cell transplant and those receiving long-term treatment with steroids or other medications that suppress cell-mediated immunity. Pulmonary nocardiosis is the most common clinical presentation. The central nervous system (CNS) is the most common extrapulmonary location for nocardiosis. HIV patients with very low CD4 and high viral load are especially vulnerable to nocardia and disseminated disease. CASE: A 36-year-old man with a history of HIV/AIDS [absolute CD4 count 13 and Viral load of > 1 million while non-adherent with antiretroviral therapy (ART)] and previously treated pulmonary nocardiosis (July 2021), presented in November 2021 with progressive fever, sweats, and chills and new onset altered mental status, urinary incontinence, and seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head showed multiple ring enhancing lesions concerning for CNS nocardiosis especially in the setting of antibiotics and ART non-adherence. In addition, brain lesions were concerning for CNS toxoplasmosis especially in the setting of non-adherence to prophylactic trimethoprim-sulfamethoxazole (TMP- SMX). MRI brain demonstrated a 6 mm midline shift and lumbar puncture (LP) was deferred. The patient was started on steroids due to brain lesions, trimethoprim-sulfamethoxazole and imipenem, which was later transitioned to ceftriaxone based on previous lung culture susceptibility data. On day two after initiating treatment, the patient became more alert. Repeat brain imaging after 14 days of initiating treatment was planned to monitor disease progression, adequacy of current therapy, and to determine the possibility of obtaining an LP or biopsy to confirm diagnosis. DISCUSSION: Differentiating between CNS nocardiosis and CNS toxoplasmosis is difficult in patients who are vulnerable to both, such as in HIV infected patients with CD4 count < 50. LP and even lesion biopsy might confirm the diagnosis but may not be easy to obtain in patient with extensive brain lesion especially in the setting of high ICP with midline shift. Fortunately, tailoring treatment to cover both pathogens is not problematic.
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