PMC9834524_01
Chest CT. Coronal CT image shows a consolidation with cavitation in the center located at the right upper lobe of the lung.
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A chest computed tomography (CT) scan revealed consolidation in the right lung vertex (Figure 1).
Brain MRI. FLAIR sequence axial sections (A, B), cortical and subcortical rounded heterogeneous lesions in different sizes with perilesional edema. (C) Heterogeneous cortical and subcortical lesions at the right temporal lobe, bilateral occipital paramedial with surrounding edema. (D) At the posterior fossa: bilateral confluent lesions in the right cerebellum and cerebellar peduncle. Note the arrows represent lesions.
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A magnetic resonance imaging (MRI) of the brain revealed rounded lesions at basal ganglia and bilateral subcortical cortical lesions in the frontal, parietal, and temporal lobes with bilateral cerebellar lesions of different sizes on T2-weighted imaging (T2-WI) and Fluid-attenuated inversion recovery-weighted imaging (FLAIR-WI) (Figure 2).
Contrast MRI and spectroscopy. (A, B) Contrast-enhanced Brain MRI T1 sequence, axial section: rounded lesions with ring enhancement near the basal ganglia, posterior commissure, and temporal lobe, right side (C) coronal section, rounded lesions at the supra and infratentorial level in enhancement contrast ring. (D) Spectroscopy study shows (arrow) low levels of the choline metabolite with a choline and creatine ratio of 0.12, suggestive of lesions of infectious origin.
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Brain MRI with spectroscopy showed a peak of choline that confirmed neuro infection (Figure 3).
Microbiology studies. (A) Gram stain: Branched Gram-positive Bacillus. (B) Kinyoun stain: resistant acid alcohol branched bacteria. (C) Culture in Sabouraud: plaster-like folded yellowish-white colonies (popcorn) identification. Nocardia species.
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After consulting the neurosurgery department, a CT-assisted stereotactic brain biopsy of the lesions was obtained with no apparent complications, and samples were analyzed with Kinyoun stain confirming the presence of filamentous gram-positive bacillus compatible with Nocardia (Figure 4).