Disclosures: Christopher Amen, DO: No financial relationships or conflicts of interest

Case Description: 63 year-old male with five weeks of headaches, left-sided weakness, paresthesias, and hemoptysis. Significant social/vocational history of recent excavation, tooth abscesses, and a sinuplasty procedure. CTA of brain and lungs suggested metastatic malignancy versus abscesses. MRI of the brain showed multiloculated lesions suggestive of abscesses and vasogenic edema. Brain biopsy confirmed abscesses, and cultures sent. Initial microscopy suggested actinomycetes. Patient placed on six weeks of penicillin G and discharged to rehabilitation unit. On admission, patient demonstrated left-sided UMN signs (clonus, Hoffman’s sign) and weakness. Patient rapidly developed bilateral lower extremity sustained clonus and spasticity. Repeat MRI indicated worsening vasogenic edema to both hemispheres and persistent brain lesions. Initiated IV decadron to address worsening vasogenic edema despite concern for further dissemination. The clonus and pain were dramatically improved after administration of IV decadron. Cultures from brain abscesses returned, confirming Nocardia farcinica. Patient switched to Meropenem. MRI at discharge demonstrated treatment response and decreased vasogenic edema.

Setting: Acute Inpatient Rehabilitation

Patient: 63 year-old male with disseminated nocardiosis Assessment/

Results: His ambulation deteriorated to 50 feet using a rolling walker with moderate assistance x2. After initiation of decadron, patient had rapid improvements in ambulation. He ambulated 90 feet minimally assisted after four days of treatment, 135 feet with a single Lofstrand crutch at five days and was nearly independent after 11 days.

Discussion: This patient presented with late neurologic complications of disseminated Nocardia farcinica. Few case reports describe the rehabilitation medicine considerations and complications of disseminated nocardiosis. The progression of the vasogenic edema manifested as worsening of pain and spasticity, and development of bilateral UMN signs. He had significant deterioration in ambulation secondary to these worsening deficits.

Conclusion: Steroids should be considered in patients with worsening vasogenic edema secondary to systemic nocardiosis. Confirming proper antibiotic coverage prior to administration of steroids is preferred to minimize risk of further dissemination.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/systemic-nocardiosis-late-neurologic-complications-and-considerations-in-rehabilitation/