(540) When Two Conditions Collide, Disseminated Nocardiosis Mimicking Neurosarcoidosis: A Case Report

Introduction: Disseminated Nocardiosis is defined as the infectious involvement of two or more locations. It is associated with underlying immunosuppression. The most commonly involved organs are the lung, brain, and skin. We present a rare case of a 65-year-old man with disseminated Nocardiosis due to immunocompromise from chronic glucocorticoid therapy for Sarcoidosis.

Description: A 65-year-old man with End Stage Renal Disease and Sarcoidosis with neurologic involvement, treated with chronic glucocorticoid therapy was admitted for altered mental status and new onset right hip pain. Prior to admission, glucocorticoid dosage was increased due to worsening respiratory status. Imaging demonstrated fluid collections in the right hip joint and surrounding muscles. Additionally, multiple masses were seen on the left temporal lobe initially attributed to his neurosarcoidosis. The patient was started on Vancomycin, Cefepime, and Flagyl, and his home dose of oral prednisone was resumed for suspicion of worsening neurosarcoidosis leading to his altered mental status. The patient underwent surgical resection of the previously seen fluid collection in the lower limb but subsequently developed postoperative shock. Wound cultures grew branching organisms, and a PCR later confirmed Nocardial infection. IV Bactrim, imipenem, and amikacin were added per Infectious Disease recommendations. A repeat brain MRI was obtained due to concerns for disseminated intracranial Nocardiosis. It suggested multiple new lesions scattered bilaterally and a significant increase in the size of the temporal masses. The primary source of his disseminated Nocardiosis was thought to be the lung as the chest CT showed extensive consolidations, ground glass opacities, and architectural distortion in the bases. Due to the extensive nature of his Nocardial infection and other comorbidities including pneumothorax and ESRD, his family pursued comfort measures.

Discussion: Although rare, Disseminated Nocardiosis has a high mortality rate, especially with CNS involvement. Our case demonstrates the severity of a disseminated infection in an immune-compromised patient. Clinically differentiating between neurosarcoidosis and disseminated Nocardiosis was challenging in our case. Underlying risk factors are useful clues to reach the correct diagnosis.