Nocardia farcinica meningitis in a patient with high-grade astrocytoma

We describe a case of 91-year-old male with astrocytoma who developed meningitis caused by Nocardia farcinica. He had a past medical
history of anaplastic astrocytoma grade III. Endocranial computed tomography (CT) scan revealed mass lesion in the left occipital region
associated with perilesional edema, without evidence of midline shift issue. The analyses of cerebrospinal fluid (CSF) revealed neutrophilic
pleocytosis, hyperproteinorrachia and hypoglycorrhachia. Combined antimicrobial therapy was initiated (vancomycin, meropenem, acyclovir).
CSF culture revealed Nocardia farcinica. Susceptibility testing revealed intermediate sensitivity to meropenem and antibiotic treatment was
switched to trimethoprim-sulfamethoxazole and imipenem. After 7 days of treatment the patient developed progressive dyspnea. The chest CT
scan revealed bilateral pleural effusion and alveolar infiltrate mostly in the right lobe. Ceftriaxone was added to the therapy, but the outcome
was lethal. Nocardia spp. should be considered as differential diagnosis in the patients with brain tumor or meningitis in the setting of immune
suppression and corticosteroid use. CSF cultures should be incubated longer with aim to allow fastidious organisms to grow, such as Nocardia
spp.