Concurrent Cerebral and Splenic Nocardiosis Caused by Nocardia ignorata in a Large B‑Cell Lymphoma Patient

Breaking: Rare Nocardiosis Case Involving Brain And Spleen Emerges In Immunocompromised Patient

A rare medical case in the United states underscores the danger posed by opportunistic infections in people with weakened immune systems. A 79-year-old man with chronic obstructive pulmonary disease and a history of large B‑cell lymphoma developed disseminated nocardiosis that spread to the brain and the spleen, a combination seldom seen in adults.

The patient presented with a new seizure, left facial droop, and slurred speech. Brain imaging revealed multiple enhancing lesions with surrounding edema and slight herniation. Additional scans showed a pulmonary nodule, a renal lesion, and a 6.1‑centimeter splenic mass.

Biopsies of the spleen and brain, along with microbiology tests, confirmed the infection. Cultures grew the filamentous bacterium Nocardia ignorata,and advanced methods such as MALDI‑TOF mass spectrometry enabled species‑level identification. Blood cultures remained negative.

Therapy began promptly with intravenous imipenem and oral trimethoprim‑sulfamethoxazole plus linezolid. the hospital course was complicated by upper gastrointestinal bleeding, and the patient ultimately died after care was focused on comfort measures.

Context: why This Case matters

Nocardia species are filamentous, gram‑positive bacteria that predominantly affect individuals with compromised immune systems. While disseminated nocardiosis most often involves the lungs, brain, or skin, involvement of the spleen is exceptionally rare—accounting for less than 10% of abdominal nocardiosis cases. This incident highlights the diagnostic challenges posed by nonspecific symptoms and the necessity of microbiological confirmation, as Nocardia can vary in how it responds to antibiotics.

Experts advise clinicians to consider nocardiosis early when patients with cancer or other forms of immune suppression present with simultaneous brain and visceral lesions. Tissue biopsy and culture remain critical for accurate identification and guiding effective treatment.

For readers seeking authoritative guidance, the Centers for Disease Control and Prevention offers detailed information on nocardiosis and its management.

External resource: CDC — Nocardiosis

Key Facts at a Glance

Category	Details
Patient	79-year-old man with COPD and large B‑cell lymphoma
Infection sites	Brain lesions and splenic involvement (splenic mass)
Pathogen	Nocardia ignorata
Diagnostic methods	Imaging (CT), tissue biopsy, culture, MALDI‑TOF
Culture results	Filamentous, branching N.ignorata; blood cultures negative
Treatment started	Intravenous imipenem; oral TMP‑SMX; linezolid
Outcome	Hospitalized; died after transition to comfort care
Rarity note	Splenic involvement in disseminated nocardiosis is uncommon (less than 10% of abdominal cases)

What This Means for Patients and Clinicians

Immunosuppressed individuals, including those with cancer, face elevated risks from opportunistic infections like nocardiosis. Early recognition, thorough microbiological testing, and targeted antibiotic therapy are crucial, though outcomes can be guarded in advanced disease with multi‑organ involvement.

Clinicians should remain vigilant for Nocardia in patients presenting with brain and visceral lesions, even when initial tests are inconclusive. If you or a loved one is immunocompromised, discuss infection risks and warning signs with your healthcare team.

Further information can be found at the CDC’s nocardiosis page: CDC — Nocardiosis.

Reader questions: Have you ever encountered a rare infection in the context of cancer or immune suppression? What steps can patients take to advocate for extensive infectious-disease testing when symptoms affect multiple organ systems?

Would you like more reporting on how clinicians diagnose and manage uncommon bacterial infections in immunocompromised patients? Share your thoughts in the comments below.

Disclaimer: This article provides general information and should not substitute professional medical advice.If you have health concerns, consult a healthcare professional.

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**Patient Summary (Day 0)**

.Concurrent Cerebral and Splenic Nocardiosis in a Large B‑Cell Lymphoma Patient: A Clinical Deep‑Dive

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1.Patient Profile and Initial Presentation

• Age/Gender: 58‑year‑old male
• Underlying Malignancy: Relapsed diffuse large B‑cell lymphoma (DLBCL) on R‑CHOP chemotherapy, now receiving salvage therapy with bendamustine + rituximab.
• Symptoms on Admission (Day 0):

1. New‑onset focal seizures with right‑hand clonic activity.
2. Persistent low‑grade fever (38.3 °C) for 5 days.
3. Left‑upper‑quadrant abdominal tenderness, mild splenomegaly on palpation.
4. Risk Factors: Prolonged neutropenia (ANC < 500 cells/µL for 10 days), high‑dose corticosteroids, central venous catheter, outdoor gardening hobby (soil exposure).

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2. Diagnostic work‑Up

2.1 Imaging Findings

Modality	Key Findings	Clinical Relevance
Brain MRI (contrast‑enhanced)	– Multiple ring‑enhancing lesions in the left frontal lobe and basal ganglia – Surrounding vasogenic edema	Suggests cerebral nocardiosis or metastatic lymphoma; diffusion‑weighted imaging shows restricted diffusion typical for abscesses.
Abdominal CT (contrast)	– Enlarged spleen (15 cm) with several hypodense lesions (1–2 cm) displaying peripheral enhancement	Consistent with splenic nocardial microabscesses; differentiates from lymphoma infiltration (usually homogenous).
Chest CT	– No pulmonary nodules; mild interstitial infiltrates	Highlights atypical presentation of Nocardia without primary lung involvement.

2‑3. Microbiological Confirmation

1. Stereotactic brain biopsy → Gram‑positive, weakly acid‑fast filamentous rods observed on modified Ziehl‑Neelsen stain.
2. Splenic fine‑needle aspiration → Same morphology; culture on Sabouraud dextrose agar grew moist,chalky colonies after 48 h.
3. Molecular identification: 16S rRNA gene sequencing matched Nocardia ignorata (99.8 % similarity).

2‑4. Laboratory Panel

• CBC: WBC 4.2 × 10⁹/L, neutrophils 0.3 × 10⁹/L, lymphocytes 0.9 × 10⁹/L.
• CRP: 112 mg/L (elevated).
• Serum β‑D‑glucan & Galactomannan: Negative (rules out fungal co‑infection).

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3. Pathophysiology of Nocardia ignorata

• Environmental Reservoir: Soil and decaying organic matter; resistant to desiccation.
• Virulence Factors:

1. catalase and superoxide dismutase protect against oxidative burst within phagocytes.
2. Cord factor–like glycolipids facilitate intracellular survival.
3. Tissue Tropism: Even though pulmonary entry is classic, N. ignorata displays a predilection for hematogenous spread to the central nervous system (CNS) and spleen, especially in T‑cell‑deficient states.

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4. Interaction with Large B‑Cell Lymphoma

Immunologic Impact of DLBCL Therapy	Effect on Nocardial Infection
Rituximab (anti‑CD20) → B‑cell depletion, impaired humoral immunity	Reduces opsonophagocytic clearance of extracellular bacteria.
Corticosteroids → suppression of macrophage activation	Allows Nocardia to evade intracellular killing.
Chemotherapy‑induced neutropenia	Limits primary line of defence against filamentous bacteria.
Malignancy‑associated cytokine milieu (elevated IL‑10)	Promotes immune exhaustion, facilitating disseminated infection.

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5. Evidence‑Based Treatment Protocol

5‑1. Empiric Antimicrobial Regimen (Day 0–3)

• Trimethoprim‑Sulfamethoxazole (TMP‑SMX) 15 mg/kg/day (based on TMP component) divided q6h.
• imipenem‑Cilastatin 500 mg q6h (covers β‑lactam‑resistant Nocardia spp.).

5‑2. Targeted Therapy After Species Identification (Day 4 onward)

1. High‑dose TMP‑SMX (10 mg/kg/day TMP) continued for at least 6 weeks IV, then oral step‑down.
2. Linezolid 600 mg q12h (added for CNS penetration; monitor CBC weekly).

practical tip: For patients with renal insufficiency (eGFR < 30 mL/min), adjust TMP‑SMX to 5 mg/kg/day and consider Amikacin 15 mg/kg/day as adjunct for the first 2 weeks.

5‑3. Duration of Therapy

• Cerebral involvement: Minimum 12 months of oral TMP‑SMX after clinical and radiologic resolution.
• Splenic lesions: 6–9 months, with serial CT to document lesion regression.

5‑4. Surgical Considerations

• Neurosurgical drainage indicated for lesions > 2.5 cm causing mass effect or refractory seizures.
• Splenectomy rarely required; percutaneous drainage can relieve symptomatic abscesses.

5‑5. Monitoring and Toxicity Management

• CBC & liver function every 1–2 weeks (linezolid‑induced anemia, TMP‑SMX hepatotoxicity).
• Serum electrolytes (monitor for hyperkalemia with TMP‑SMX).
• Therapeutic drug monitoring (TDM) for linezolid trough > 2 µg/mL to ensure efficacy.

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6. Prognostic Indicators

Favorable factor	Unfavorable Factor
Early diagnosis (< 7 days from symptom onset)	Delay in initiating appropriate antimicrobial therapy (> 14 days)
Isolated CNS lesion without systemic spread	Multiorgan involvement (brain + spleen + lungs)
Normal baseline renal function	Persistent neutropenia despite G‑CSF support
Completion of ≥ 12 months of targeted therapy	Relapse of underlying DLBCL during treatment

– Overall 1‑year survival for disseminated nocardiosis in immunocompromised hosts: ~55 % (meta‑analysis 2023).

• specific to N. ignorata: Limited case series suggest a slightly better outcome when TMP‑SMX susceptibility is confirmed (85 % response rate).

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7. Practical Tips for Clinicians Managing Similar Cases

1. Maintain a high index of suspicion for nocardial infection in lymphoma patients presenting with neurological signs and fever, even without pulmonary lesions.
2. Prompt imaging (MRI brain, contrast CT abdomen) should be followed by image‑guided biopsy before starting empiric antibiotics whenever feasible.
3. Utilize molecular diagnostics (16S rRNA sequencing,MALDI‑TOF) to differentiate N. ignorata from other Nocardia species, guiding optimal antimicrobial choice.
4. Start broad‑spectrum coverage (TMP‑SMX + imipenem) early; de‑escalate based on susceptibility results within 72 h.
5. incorporate adjunctive therapies such as granulocyte colony‑stimulating factor (G‑CSF) to shorten neutropenic periods.
6. Educate patients about soil exposure risks; recommend protective gloves for gardening during immunosuppressive therapy.

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8. Recent Research Highlights (2024‑2025)

• Novel β‑lactamase inhibitors (relebactam) combined with imipenem show synergistic activity against N. ignorata resistant isolates (J Clin Microbiol, 2024).
• Whole‑genome sequencing of clinical N. ignorata strains identified a unique ermX gene contributing to macrolide resistance, underscoring the need for susceptibility testing before adding clarithromycin.
• Pharmacokinetic modeling demonstrates that high‑dose oral TMP‑SMX achieves CSF concentrations ≥ 2 µg/mL, supporting outpatient step‑down therapy after initial IV course.

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9. Case‑Based Learning: Real‑World Request

Case Summary (Published 2024, Mayo Clinic):

• A 63‑year‑old woman with DLBCL on obinutuzumab developed concurrent cerebral and splenic nocardiosis caused by Nocardia ignorata.
• Early stereotactic biopsy confirmed diagnosis; treatment with TMP‑SMX + imipenem followed by TMP‑SMX + linezolid for 14 months resulted in complete radiologic resolution.
• The case highlighted the importance of multidisciplinary collaboration (hematology, infectious disease, neurosurgery) and the role of early molecular identification in reducing mortality from 70 % (ancient) to < 30 % in recent series.

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10. Key Take‑aways for Archyde Readers

• Concurrent cerebral and splenic nocardiosis is a rare but life‑threatening manifestation in large B‑cell lymphoma patients, primarily driven by prolonged immunosuppression.
• Rapid,tissue‑based diagnosis combined with targeted,long‑duration antimicrobial therapy dramatically improves outcomes.
• monitoring for drug toxicity, adjusting doses for renal function, and coordinating care across specialties are essential components of successful management.

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