Nocardia farcinica masquerading as intracerebral metastases in advanced metastatic prostatic cancer

Abstract

A 67-year-old man with metastatic prostate cancer and underlying asymptomatic pancytopenia presented with a 1-week history of general malaise, left leg weakness and facial numbness. Initial brain imaging demonstrated two rim-enhancing lesions felt to represent intracerebral metastasis. Following neurosurgical referral, a multidisciplinary meeting decision was made for best supportive care and dexamethasone was given. He developed multiple cutaneous lesions, which on incision and drainage revealed Nocardia farcinica. Repeat brain imaging showed enlargement of the existing cavitating lesions and appearance of new lesions, now typical of cerebral abscesses. A diagnosis of disseminated nocardiosis with cutaneous and intracerebral infection was reached. He started taking empirical treatment with intravenous meropenem, co-trimoxazole and subsequent addition of amikacin, with little improvement. On further review of sensitivities, moxifloxacin was added. Following over 1 month of antimicrobial treatment, his neurological symptoms, cutaneous lesions and repeat MRI of the brain had improved.