A 42-year-old man without any previously known medical history contacted his general physician due to complaints of cough and dyspnea. He was predisposed toward pulmonary illness through daily smoking of tobacco and inhaled illicit drugs of poor quality. Furthermore, the patient had a chronic occupational exposure to concrete and limestone, two known sources of silica dust.
He was prescribed general antibiotics, but was admitted at Shariati Hospital, Isfahan 3 months later due to the persistence of his symptoms. During admission, x-ray and computerized tomography (CT)-scan of the thorax were performed, which were suggestive of pneumonia; then the patient was represcribed antibiotics and discharged.
One month later the patient's condition worsened, now presenting with fever (39.8 C), daily headache, and vomiting. Brain magnetic resonance imaging (MRI)-scan with contrast was performed, which revealed multiple bilateral brain abscesses [Figure 1a] causing his immediate transfer to Arad Hospital, Tehran for stereotactic brain biopsy. The biopsy material was cultivated and examined by smear microscopy, which indicated long 1 microm-wide, branching, filamentous, gram-positive elements suggestive of Nocardia, or less likely fungi, which at that point could not be confirmed by culture. The patient was referred to Alzahra Hospital, Isfahan and the treatment was expanded to consist of vancomycine, meropenem, trimetroprime/sulfametoxazol (TMP/SMX), amphotericin B, and dexamethasone.
In the search for a primary focus of infection, and with cancer as the differential diagnose, the patient was systematically examined. At first an echocardiogram following blood cultivation of three independent blood samples was performed in order to rule out endocarditis, all of which turned out negative. The chest CT-scan was inconclusive showing diffuse alveolar infiltrations [Figure 2]. Further smear microscopy and culture were performed on sputum and bronchoalveolar lavage (BAL) but they showed negative for Actinomyces, Nocardia, Mycobacterium Tuberculosis, and other bacteria and fungi. Cytopathology analysis for malignancy was also performed but turned out negative. The abdomen and pelvic were assessed using CT-scan with contrast and ultrasonography but revealed no abnormalities. Neither did the urine analysis nor did the culture show any sign of infection. When assessing the patient's immunocompetence the patient was tested negative three times for HIV type 1 and 2, and a complete blood and bone marrow analysis was performed including CD8+ and CD4+ T-cell count, which revealed no immunodeficiency, malignancy, or sign of tuberculosis. Finally, an open lung biopsy was performed. This revealed PAP, but was negative for malignancies, Actinomyces, Nocardia, Mycobacterium Tuberculosis and other bacteria, confirming the negative results of sputum and BAL analysis.
3 weeks after the brain biopsy the result of the brain abscess culture was completed and turned out positive for Nocardia Asteroides, confirming the results of the smear. Based on these results, a 2 months intravenous drug regime was started consisting of TMP/SMX, meropenem, and amikacine. Neurosurgical intervention was also considered due to the large size of the abscesses, but was not found to be possible because of the high number of abscesses and the profound location. Dexamethasone was also prescribed and it showed a beneficial effect on the headache but its tapering was complicated due to the return of headaches. After 3 weeks of treatment the fever began to diminish, and after 2 months the patient was discharged with a body temperature of 37.2 C and a reduction in the frequency of vomiting and headaches from a daily basis to a weekly basis. The treatment was continued with oral TMP/SMX antibiotics.
Four months after discharge the patient returned to the hospital with newly-emerged neurological and psychological symptoms such as diplopia, headaches, and breakdowns despite continuous oral antibiotic treatment and brain MRI-scan with contrast that on the contrary was showing diminished cerebral abscesses [Figure 1b]. Because of the worsening condition and the increasing neurological character of the symptoms, the patient was discontinued treatment at the infectious disease department and transferred to the neurology department for further treatment.