Teaching NeuroImages: The tetraplegic gardener - A case of CNS nocardiosis in an immunocompetent patient

Summary

  • 36yo M
  • HPI
    • immunocompetent
    • progressive spastic tetraplegia
  • Ex
    • T2WI RMI
    • T1WI
      • C2-T4 lv
      • epidural / subdural compartment
      • intramedullary hyperintensities
    • skin biopsy

Further

Terminology

Original

A 36-year-old immunocompetent male gardener with chronic skin lesions (figure 1) presented with a 6-month history of progressive spastic tetraplegia. Cervical imaging showed soft tissue lesions at the C2-to-T4 level with extension to the epidural/subdural compartments along with longitudinal intramedullary hyperintensities (figure 2). Skin biopsy revealed Nocardia brasiliensis.

Figure 1

Figure.1

Nocardiosis skin lesions
Skin lesions throughout the left upper limb and posterior cervical region.

Figure 2

Figure.2

RMI shows cutaneous-spinal fistula secondary to nocardiosis skin lesions
Sagittal T2-weighted RMI image (A) and sagittal (B) and axial (C) T1-weighted images after contrast show multiple epidural collections surrounding the cervical spine (prevertebral: arrowheads; perimedullary: arrows), causing extensive compressive medullary edema (point). Also note a fistula connecting the skin to the spinal canal (star). Peripheral lymphadenopathy is seen (cross).

Nocardia brasiliensis is an aerobic, filamentous gram-positive pathogen that typically inhabits the soil—hence its association with gardening.1 It generally causes skin infection, mostly in immunocompromised patients. Rarely does nocardiosis affect the CNS; its early recognition, however, is of paramount importance because it guides management and influences prognosis.2

References

  1. Anagnostou T, Arvanitis M, Kourkoumpetis TK, et al. Nocardiosis of the central nervous system experience from a general hospital and review of 84 cases from the literature. Medicine 2014;93:19–32.
  2. Saubolle MA, Sussland D. Nocardiosis: review of clinical and laboratory experience. J Clin Microbiol 2003;41:4497–4501.