Nocardia Brain Abscess and Cytomegalovirus Meningoencephalitis in a Kidney Transplant Patient

Introduction: Nocardia mainly affects immunosuppressed people with 20-50% infections disseminating to the brain. CMV infection can result in meningoencephalitis in the immunocompromised. Both Nocardia and CMV infections can cause significant morbidity for transplant recipients. We present a kidney transplant (KT) recipient with co-existing CMV meningoencephalitis and Nocardia brain abscess. Case Description: 75 YO woman, 6 months s/p DDKT, presented to the hospital with AMS and fever. Brain MRI demonstrated a 3 cm abscess in the left frontal lobe. LP was performed with detection of CMV by PCR and isolation of Nocardia veterana in the CSF. Brain abscess biopsy demonstrated purulent and necrotic debris within brain tissue. GMS stain revealed finely filamentous organisms, and Nocardia veterana was isolated in AFB culture. Source of infection was felt to be soil inhalation given pulmonary nodules on chest CT. Her immunosuppression regimen was adjusted. She was treated with IV trimethoprim-sulfamethoxazole and meropenem for the Nocardia brain abscess, and with IV ganciclovir for the CMV meningoencephalitis. She had full neurological recovery at 7 weeks and is now 26 weeks out from initial diagnosis with excellent allograft function. Discussion: A dual diagnosis of CMV meningoencephalitis and Nocardia brain abscess post KT is rare; with no other cases reported in the literature. The outcomes of nocardiosis and delayed post-prophylactic CMV disease depend on the site of infection and host immune status. Nocardial CNS infections confer a high mortality rate – up to 85% in immunosuppressed patients. However, early diagnosis and prompt treatment can achieve cure rates up to 50-85%. CMV disease in kidney transplant recipients can increase the risk of mortality by more than 50%. This case demonstrates the importance of early diagnosis and treatment of these virulent infections in transplant recipients so that successful outcomes can be achieved.1a.Reactive changes.in brain tissue1c.Filamentous organisms GMS stain