Nocardial meningitis: case reports and review

Twenty-eight episodes of nocardial central nervous system infection fulfilling criteria for meningitis were reviewed. In 21 cases Nocardia was cultured from cerebrospinal fluid (CSF). Associated predisposing conditions were present in 75% of cases. The typical presentation was subacute to chronic meningitis characterized by fever (68%), stiff neck (64%), and headache (55%). CSF studies revealed neutrophilic pleocytosis (83% of cases, greater than 500 white blood cells/mm3), hypoglycorrhachia (64%, less than 40 mg of glucose/dL), and elevated protein level (61%, greater than 100 mg/dL). In 43% of cases there was an associated brain abscess. Patients with brain abscess had more frequent and severe aberrations in mental status as well as higher initial white blood cell counts in CSF. Mortality was 52% for the 23 cases diagnosed antemortem and 57% overall. Compared with patients who died, survivors were younger, had lower initial CSF glucose levels, and were less likely to have brain abscess. Diagnosis was often delayed, and nocardial infection was rarely suspected before positive culture reports or autopsy findings became available.