PMC9062894_01
(a) Preoperative the brain CT in the axial plane shows the low-density area in the right parietal lobe. (b) The enhanced T1-weighted MRI axial image revealed that polycystic ring-enhancing lesions with surrounding vasogenic edema in the right parietal lobe. (c) Gram stain for brain pus showing Gram-positive actinomyces with beaded staining pattern. (x1000). (d) Kinyoun smear stain showing a cluster of filamentous branching rods that are partially acid fast, which is characteristic for Nocardia (x1000).
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F1
On day 1 of admission, the initial brain CT in the axial plane shows the low-density area in the right parietal lobe [Figure 1a]. Moreover, we suspected a cerebral abscess because a multilocular cystic lesion, which was imaged in a ring shape, was observed on the enhanced T1-weighted magnetic resonance imaging axial image [Figure 1b]. Since the culture specimen was positive for Kinyoun staining, Gram-positive bacilli were found to belong to the Nocardia genus [Figures 1c and d].
(a) MALDI-TOF mass spectra of the extract from a patient's abscess (b): Nocardia thailandica (identification score: 1.731) The comparison between the raw MALDI-TOF mass spectra and the most possibility reference mass spectra. Yellowish-green, yellowish, and reddish spectra indicated as correct, possible, and difference to the reference mass spectra of the database, respectively.
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F2
On day 15 of admission, vancomycin was discontinued because it was later determined as N. thailandica based on the 16S rRNA sequence and matrix-assisted laser desorption ionization time-of-flight mass spectrometry [MALDI-TOFMS; Figures 2a and b].
Postmortem specimens of the patient. (a) Gross brain section showing a collapsed abscess in the right parietal lobe (arrow). (b) H.E. stain revealed that no viable bacteria was in and around the cerebral abscess (x100). (c) Gross appearance of lung showing an abscess occupying the right inferior lobe (arrow). (d) Aspergillus (arrow) and Candida (arrow head) genus were seen in the lung abscess stained with H.E. (x100).
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F3
Since filamentous fungi, suspected of Aspergillus, and yeast-like fungi, suspected of Candida, were detected in the abscesses and blood vessels, the cause of death was established as aspergillosis and disseminated candidiasis due to bacterial replacement caused by the prolonged administration of antibiotics [Figure 3].