Disseminated nocardiosis as a complication of Evans' syndrome

Nocardiosis is an opportunistic infection caused by gram-positive, weakly a cid-fast filamentous aerobic organisms. Three species cause infection in ma n: N. asteroides, N. brasiliensis, and N. caviae, the first one being the m ost common. With increased use of immunosuppressive therapy for various aut oimmune diseases, opportunistic infection by Nocardia has increasingly been reported. N. asteroides infections manifest in various ways; the lungs, sk in, and brain are the organs most frequently involved. We describe a patien t with Evans' syndrome, a disease requiring long-term immunosuppression, wh o acquired systemic nocardiosis. The infection was primarily pulmonary, mis diagnosed as tuberculosis, with subsequent hematogenous dissemination to th e skin and central nervous system. The diagnosis of cerebral involvement wa s difficult to prove, as the patient presented with stroke-like episodes. A fter a positive blood culture was obtained, antibiotic therapy was introduc ed. The patient's condition deteriorated and the brain with infiltration of the meninges, lungs, skin, and kidneys. Nocardia is an important but often overlooked opportunistic infectious agent in immunocompromised hosts, caus ing diagnostic and therapeutic problems. As the mortality of cerebral nocar diosis is greater than 80%, early diagnosis and appropriate therapy are cru cial.