Ruptured mycotic cerebral aneurysm secondary to disseminated nocardiosis

We report a case of a ruptured mycotic cerebral aneurysm caused by Nocardia infection. A 22-year-old immunocompromised woman with adult-onset Still's disease developed a subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a small aneurysm at the M2-3 bifurcation of the right middle cerebral artery. Cardiac ultrasonography showed vegetation at the posterior cardiac wall, suspecting infective endocarditis (IE). Gram-positive filamentous bacteria were observed in the necrotic tissue surrounding the aneurysm obtained during trapping surgery. Long-term blood culture showed that the cause of her cerebral mycotic aneurysm was nocardiosis. A mycotic ruptured cerebral aneurysm is an important cause of SAH in immunocompromised patients. Early diagnosis of IE, detection of gram-positive rods by Gram staining, and long-term culture to identify the bacteria is crucial in diagnosing nocardiosis.

Key-words:

Immunosuppressed host - nocardiosis - ruptured mycotic cerebral aneurysm

Financial support and sponsorship

Japan Society for the Promotion of Science KAKENHI Grant-in-Aid for Scientific Research (C) No. JP17K10819, and Grant-in-Aid for Scientific Research (B) No. 20H03787.

Publication History

Received: 26 February 2020

Accepted: 01 September 2020

Article published online:
16 August 2022

• References

• 1 Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev 2006;19:259-82.
• 2 Long PF. A retrospective study of Nocardia infections associated with the acquired immune deficiency syndrome (AIDS) Infection 1994;22:362-4.
• 3 Tremblay J, Thibert L, Alarie I, Valiquette L, Pépin J. Nocardiosis in Quebec, Canada, 1988-2008. Clin Microbiol Infect 2011;17:690-6.
• 4 Chansirikarnjana S, Apisarnthanarak A, Suwantarat N, Damronglerd P, Rutjanawech S, Visuttichaikit S, et al. Nocardia intracranial mycotic aneurysm associated with proteasome inhibitor. IDCases 2019;18:e00601.
• 5 Farran Y, Antony S. Nocardia abscessus-related intracranial aneurysm of the internal carotid artery with associated brain abscess: A case report and review of the literature. J Infect Public Health 2016;9:358-61.
• 6 Hadley MN, Spetzler RF, Martin NA, Johnson PC. Middle cerebral artery aneurysm due to Nocardia asteroides: Case report of aneurysm excision and extracranial-intracranial bypass. Neurosurgery 1988;22:923-8.
• 7 Kim S, Lee KL, Lee DM, Jeong JH, Moon SM, Seo YH, et al. Nocardia brain abscess in an immunocompetent patient. Infect Chemother 2014;46:45-9.
• 8 Lerner PI. Nocardiosis. Clin Infect Dis 1996;22:891-903.
• 9 Frazee JG, Cahan LD, Winter J. Bacterial intracranial aneurysms. J Neurosurg 1980;53:633-41.
• 10 Koh M, Tomita T, Kashiwazaki D, Ashizawa N, Yamamoto Y, Kuroda S. Disseminated nocardiosis complicated by multiple brain abscesses: A case report. No Shinkei Geka 2015;43:1091-7.
• 11 Nocaridosis MikamiN. Actinomycete. Jpn J Med Mycol 2007;48:186-8.
• 12 Allen LM, Fowler AM, Walker C, Derdeyn CP, Nguyen BV, Hasso AN, et al. Retrospective review of cerebral mycotic aneurysms in 26 patients: Focus on treatment in strongly immunocompromised patients with a brief literature review. AJNR Am J Neuroradiol 2013;34:823-7.
• 13 Weber L, Yium J, Hawkins S. Intracranial nocardia dissemination during minocycline therapy. Transpl Infect Dis 2002;4:108-12.
• 14 Morinaga A, Ohkusu K, Asano Y, Goto T, Torii T, Asano MA. Bacteriological characterization of Nocardia farinica isolates from 7 clinical cases. The J Jpn Soc Clin Microbiol 2013;23:51-8.
• 15 Hitti W, Wolff M. Two cases of multidrug-resistant Nocardia farcinia infection in immunosuppressed patients and implications for empiric therapy. Eur J Clin Microbiol Infect Des 2005;24:142-4.