A 58-year-old woman was admitted to our hospital with complaints of general fatigue, thirst and lumbago. A diagnosis of Cushing's syndrome was made on the basis of elevated serum levels of cortisol and adrenocorticotropic hormone (ACTH). Although Cushing's disease was most suspected, no evident image of pituitary adenoma could be found on brain CT scan and MRI. Therefore, treatment with oral Trilostane was started. Three months after admission, left hemiplegia was noticed and cerebral abscess in the right frontal lobe was demonstrated by brain CT scan. In spite of surgical removement of the abscess by total resection, she had a relapse in the same site and also developed a new lesion in the left lateral lobe.
Surgical drainage was performed and Nocardia asteroides was isolated from the drained pus.
An intensive chemotherapy with aminobenzylpenicillin (ABPC) and latamoxef (LMOX) in combination resulted in marked decrease in size of the lesion in the brain and subsequent improvement of left hemiplegia was achieved. Since approximately one month before when a diagnosis of cerebral abscess was made, there had been demonstrated a coin lesion in the right middle field on chest X-ray films. This lesion in the right lung disappeared concomitantly with the improvement of the lesions in the brain.
This fact strongly suggests that the lesion in both brain and lung were of the same nature.
Nocardia is known to make a primary lesion in the lung after being inhaled and then through hematogenous dissemination to make distant lesions in various sites, especially in the brain. Therefore, it is conceivable that the lesion in the lung observed in this patient was a primary lesion and that in the brain were developed secondarily.
The suppressed humoral and cellular immunities in this patient were evident from the results of the tests, namely, lowered serum levels of IgA and IgG, a low OKT4/OKT8 ratio, attenuated blastogenesis reactions to PHA and ConA, and weakened tuberculin skin reaction.
It is well known that immunity is suppressed in the majority of the patients with Cushing's syndrome, as observed in this case. And in this patient an underlying disease, i.e. Cushing's syndrome per se, might play a crucial role in development of pulmonary and cerebral abscess due to Nocardia.
There has been no report, to our knowledge, dealing with Cushing's syndrome associated with cerebral abscess due to Nocardia. The present particular case strongly suggests that we should bear in mind the possibility of infection due to Nocardia in addition to the other opportunistic pathogens.
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