Teaching NeuroImage: nocardial intramedullary spinal cord abscess.

A 79-year-old man with ulcerative colitis on chronic prednisone therapy developed severe midcervical pain and progressive weakness of the left arm and leg over several days. This was associated with left forearm paresthesias and urinary hesitancy and incontinence. He had no cranial or bulbar symptoms. On general examination, he was afebrile but there was midcervical spine tenderness. Neurologic examination revealed normal mental status and cranial nerves; strength was 2/5 on the left, and 4/5 on the right; there was a sensory level to pain and temperature on the right to C4, with reduced proprioception in the left foot and hand; there was a left Babinski sign and a mute right plantar response. White blood cell count was 18.2 10/L. Blood cultures were negative. Chest CT demonstrated multiple lung nodules. Cervical spine MRI (figure 1) revealed an intramedullary ring-enhancing mass on the left at C3-4 associated with edema from C2 to C7. Open spinal cord biopsy revealed Nocardia farcinica abscess (figure 2). Lumbar puncture and bronchoscopy were not performed. The patient was treated with IV trimethoprim-sulfamethoxazole and dexamethasone. After 10 days, lower extremity strength improved bilaterally. Left arm strength and sensory deficits remained unchanged. He died 8 weeks later due to cardiac arrest. No autopsy was performed. CNS nocardiosis is usually associated with systemic nocardial infection. Although brain abscess is the most common presentation of CNS nocardiosis, rare cases of intramedullary spinal cord abscess have been reported.1,2 Nocardia abscess should be considered in immunocompromised patients with spinal cord syndromes. Expeditious tissue diagnosis and antibiotic therapy are essential to improved outcomes.