CHEST Guidelines-A-53-Year-Old-Woman-With-Seizure-and-Cavitary-Lung

A-53-Year-Old-Woman-With-Seizure-and-Cavitary-Lung

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A 53-year-old woman presented with a generalized tonic-clonic seizure, prompting a head CT that revealed a left frontal lobe hypodensity suggestive of a mass with edema. She also had a recent history of a subacute productive cough with bloody sputum, and a chest CT confirmed a right upper lobe (RUL) consolidation with central cavitation. She was initially treated with doxycycline, but nonproductive cough persisted. Laboratory investigations ruled out other infections such as HIV, and her condition required a neurosurgical evaluation for the cerebral mass.<br /><br />Despite extensive testing, including negative bronchoscopy results for malignancy and bacterial cultures, PCR testing of bronchoalveolar lavage (BAL) fluid revealed Nocardia paucivorans, leading to a diagnosis of disseminated nocardiosis with central nervous system (CNS) involvement. Nocardia is a genus of filamentous bacteria known to cause infections primarily in individuals with compromised immunity, but they can affect otherwise healthy individuals, especially certain species like N. paucivorans with noted CNS tropism.<br /><br />The patient underwent a decompressive craniotomy for abscess drainage and was treated with a course of antibiotics, initially IV trimethoprim-sulfamethoxazole and imipenem, later transitioned to amikacin due to intolerance. Following eight weeks of parenteral therapy, she showed clinical improvement and was subsequently shifted to a year-long oral regimen of moxifloxacin and minocycline. Brain MRI and chest CT showed reduced lesion sizes, correlating with her improved symptoms. Despite diagnostic challenges, PCR testing confirmed nocardiosis, guiding successful treatment.<br /><br />This case underscores the importance of considering nocardiosis in patients with lung and brain lesions, even without obvious immunosuppression, and highlights PCR as a crucial diagnostic tool.

Keywords

nocardiosis

tonic-clonic seizure

frontal lobe mass

Nocardia paucivorans

CNS involvement

decompressive craniotomy

PCR testing

antibiotic therapy

immunocompetent

lung and brain lesions