The genus Nocardia consists of a group of gram-positive environmental bacteria. They typically cause lung and brain
infections in immunocompromised patients, even though one out of three infected patients have a normally functioning immune system. Being a ubiquitous microorganism, in some cases Nocardia has been associated with nosocomial acquired
infections and
surgical procedures. A review of the literature in this field follows the case report. A 47-year-old woman underwent an
endoscopic third ventriculostomy and a left retro-sigmoid
craniotomy for a
schwannoma removal. Meningeal symptoms began a week later, in association with
C reactive protein rise and
leukocytosis. Cerebrospinal fluid (CSF) examination was clear with hypoglycorrhachia, hyperprotidorrachia and polymorphonuclear cells. Cultural exam was negative. At the brain magnetic resonance imaging (MRI) purulent material was described in the occipital ventricular horns. Empirical broad spectrum
antibiotic therapy was given for 31 days until the brain MRI showed a resolution of the
infection. Ten days later, the patient was admitted to the hospital because of new meningeal symptoms. Cerebrospinal fluid culture and Polymerase-chain reaction (PCR) Multiplex for the most important
meningitis viruses and bacteria tested negative. A broad-spectrum
antibiotic therapy was started with no benefit; thus, a broad-spectrum antifungal
therapy was added with little success on clinical status. Meanwhile, a 16s and
18s rRNA PCR was executed on a previous Cerebrospinal fluid with negative results, excluding bacterial and
fungal infections. For this reason, all the
therapies were stopped. After a few days, high
fever and meningeal signs reappeared. The brain MRI showed a meningoventriculitis. An Ommaya
catheter with reservoir was inserted and the drawn CSF resulted in the growth of Nocardia farcinica. Antibiogram-based
antibiotic therapy was started with intravenous
imipenem and
trimethoprim-sulfamethoxazole, showing clinical benefit. The patient was sent home with oral
linezolid and
amoxicillin/
clavulanate for a total of 12 months of
therapy. Nocardia rarely causes post-neurosurgical complication in a nosocomial setting. This case shows the difficulty in detecting Nocardia and the importance of the correct microbiological sample and antibiogram-based
antibiotic therapy to achieve successful treatment.