Yonsei Med J.  2010 Jan;51(1):131-137. 10.3349/ymj.2010.51.1.131.

Cerebellar Nocardiosis and Myopathy from Long-Term Corticosteroids for Idiopathic Thrombocytopenia

• Frank M
• Woschnagg
• Molzer G
• Finsterer

• KMID: 1779619
• DOI: http://doi.org/10.3349/ymj.2010.51.1.131

Abstract

Infection of the central nervous system with Nocardia sp. usually manifests as supratentorial abscesses. Supratentorial and cerebellar abscesses from infection with Nocardia sp. following immunosuppression with long-term corticosteroids for idiopathic thrombocytopenia (ITP) have not been reported. An 83 years-old, human immunodeficiency virus (HIV)-negative, polymorbid male with ITP for which he required corticosteroids since age 53 years developed tiredness, dyspnoea, hemoptysis, abdominal pain, and progressive gait disturbance. Imaging studies of the lung revealed an enhancing tumour in the right upper lobe with central and peripheral necrosis, multiple irregularly contoured hyperdensities over both lungs, and right-sided pleural effusions. Sputum culture grew Nocardia sp. Neurological diagnostic work-up revealed dysarthria, dysphagia, ptosis, hypoacusis, tremor, dysdiadochokinesia, proximal weakness of the lower limbs, diffuse wasting, and stocking-type sensory disturbances. The neurological deficits were attributed to an abscess in the upper cerebellar vermis, myopathy from corticosteroids, and polyneuropathy. Meropenem for 37 days and trimethoprime-sulfamethoxazole for 3 months resulted in a reduction of the pulmonary, but not the cerebral lesions. Therefore, sultamicillin was begun, but without success. Long-term therapy with corticosteroids for ITP may induce not only steroid myopathy but also immune-incompetence with the development of pulmonary and cerebral nocardiosis. Cerebral nocardiosis may not sufficiently respond to long-term antibiotic therapy why switching to alternative antibiotics or surgery may be necessary.

Keyword

Infection; brain abscess; opportunistic; antibiotics; steroid myopathy; immunosuppression

MeSH Terms

Adrenal Cortex Hormones/*adverse effects/*therapeutic use
Aged, 80 and over
Cerebellar Diseases/*chemically induced/*diagnosis/pathology
Humans
Immunosuppression
Male
Muscular Diseases/*chemically induced/pathology
Nocardia Infections/*diagnosis
Purpura, Thrombocytopenic, Idiopathic/*drug therapy

Figure

• 

  Fig. 1 CT-scan of the thorax showing an enhancing mass lesion in the right upper lobe with central and peripheral necrosis and multiple irregularly contoured hyperdensities over both lungs.

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  Fig. 2 T1-weighted MRI images of the brain show a slightly enhancing mass lesion in the cerebellar vermis (A) and a hyperintense lesion in the right occipital lobe (B).

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