Nocardial epidural abscess: A case report

Few cases of primary Nocardial epidural abscesses have been reported in the literature over the past 50 years, with limited guidelines available for identification and management. Typically, cases involve a prior diagnosis of systemic Nocardiosis with resultant seeding of a disseminated infection to the spine. An adult with chronic low back pain and type 2 diabetes mellitus underwent three consecutive epidural steroid injections in an outpatient setting. The patient gradually developed diffuse bilateral lower extremity pain, acute urinary retention, and saddle paresthesia. Lumbar magnetic resonance imaging revealed central herniation with annular tear compressing the thecal sac and S1 nerve roots, a dorsal epidural hemorrhage, and an abscess causing severe canal stenosis at L4-L5 and L5-S1. The patient was treated with vancomycin, piperacillin-tazobactam, and methylprednisolone without improvement, ultimately requiring surgical decompression. Initial surgical cultures grew mycobacterium species prompting RIPE therapy. Symptoms continually worsened requiring repeat decompression. Final cultures grew Nocardia, which necessitated transition to linezolid and sulfamethoxazole/trimethoprim, resulting in clinical improvement. Nocardial infection is a rare cause of isolated epidural abscess that can complicate antibiotic selection, resulting in potentially delayed treatment and worsened clinical outcomes. This manuscript aims to elucidate this rare but essential caveat to epidural abscess management.