Diffuse Nocardial Spinal Subdural Empyema: Diagnostic Dilemma and Treatment Options

Nocardiosis of the central nervous system and spine, in particular, is a rare infection with significant morbidity and mortality. Treatment is usually with antibiotics and surgical drainage or biopsy. The authors report a case of a 49-year-old man who presented with chronic lower back pain and paraplegia. He was found to have spinal subdural empyema caused by Nocardia farcinica. Laminectomy and sampling of the subdural collection were performed, and the patient was treated with triple intravenous antibiotics (linezolid, amikacin and ciprofloxacin). There was no neurological recovery at follow-up. Spinal nocardiosis should be considered in the differential diagnosis of immunocompromised patients who present with diffuse spinal epidural/subdural or spinal cord abscesses, appropriately unresponsive to antibiotics. Our case provides an insight into the management challenges of this rare disease.