To present a case of multiple Nocardia brain abscesses developed following treatment with oral steroids for Sarcoidosis. Also to discuss clinical features, microbiology, histopathology, brain imaging, treatment and outcome in this unique case.

Nocardia are filamentous gram positive bacteria resembling aerobic actinomyces. Human nocardial infections generally occur in immunocompromised hosts and cause localised or systemic suppurative disease. Brain parenchymal abscess are hallmark of central nervous system nocardiosis. We here report a case of proven multiple nocardial brain abscesses  developed in a patient on steroids for pulmonary sarcoidosis.

Patient was a 42 year old male, diagnosed as pulmonary sarcoidosis (proven by high serum ACE levels, hilar lymphadenopathy in CT thorax and histopathology of hilar nodes suggestive of non-necrotising granulomatous inflammation) 6 years back following complaints of dry cough and breathlessness. Since last 5 months patient again developed respiratory complaints for which he was started on oral steroid. To us, patient presented in emergency with sudden onset headache and left hand jerky movements. On imaging, multiple conglomerated brain abscess in left temporo-parietal region were seen.

Patient was started on ATT empirically thinking tubercular infection causing brain abscess due to immunosuppressed state, but after 3 days of treatment, patient became drowsy and developed right sided weakness. Repeat imaging showed increase in size of brain abscesses with midline shift in brain. One of the largest abscess was immediately drained surgically and pus send for evaluation. To our surprise, Nocardia farcinica was detected in pus. Patient was started on oral trimethoprim/sulphamethoxazole and intravenous imipenem therapy based on sensitivity. Patient’s condition improved drastically over 2 months following treatment.

Nocardia infections pose a diagnostic dilemma, especially in tropical countries like ours. Probably steroid therapy and sarcoidosis itself caused immunocompromised state in our patient causing this gruesome disease but fortunately patient responded with appropriate treatment.