Cerebral abscess revealing nocardiosis in a patient with systemic lupus erythematosus: A challenging diagnosis

Introduction: Nocardiosis has been identified as a rare case by laboratory investigation, which was based largely on Nocardia. It is an isolated, rare, and opportunistic bacterial infection arising from a gram-positive bacterium in the environment. It tends to be found more often among immunocompromised patients, as are often SLE patients, but its diagnosis remains problematic because of its variable clinical features and isolation problem.

Case Presentation: We report the case of a 29-year-old female with a 10-year history of type 1 diabetes and a 9-year history of SLE on corticosteroid and hydroxychloroquine treatment who presented to CHU Ibn Rochd, Casablanca, with left-sided hemiparesis. She presented with painful, ?uctuating skin lesions that had continued for 15 days but did not respond to empirical antibiotics. The patient subsequently began to suffer from severe headaches, dysarthria, and hemiparesis, leading to a brain CT scan identifying several cerebral abscesses. Eventually, however, despite our initial empirical antibiotics, her condition worsened and she underwent surgical drainage. Extended culture incubation finally confirmed the diagnosis of Nocardia farcinica, prompting a change to therapy. As the patient's condition worsened, she developed a subcutaneous abdominal abscess that must be removed surgically. This patient eventually died from septic shock and multivisceral failure, despite aggressive treatment. It is not uncommon for the diagnosis of nocardiosis to be very difficult in patients with SLE, although it is already linked to the illness. Patients diagnosed with SLE usually have an uncommon diagnosis and the clinical presentation is non-specific, thus rendering appropriate therapy often non-frequent, hence the central importance of maintaining high suspicion of nocardiosis index for immunocompromised patients. Identification and adjustment of antibiotic therapy promptly is essential to improve outcomes; however, difficulties in clinical diagnosis and monitoring of nocardiosis illustrate the difficulty of managing this infection in these very at-risk populations.