Stefaniak BMC Neurology (2015) 15:183
DOI 10.1186/s12883-015-0437-7

CASE REPORT

Open Access

HIV/AIDS presenting with stroke-like
features caused by cerebral Nocardia
abscesses: a case report
James Stefaniak

Abstract
Background: Immunosuppression in Human Immunodeficiency Virus can predispose to opportunistic infections of
the central nervous system and can be life threatening without early recognition and management. This can be
delayed in undiagnosed Human Immunodeficiency Virus. The present article is the only case report in the literature
to describe a first presentation of Acquired Immune Deficiency Syndrome as cerebral Nocardia abscesses that were
initially treated as a stroke.
Case presentation: A previously well 59 year old Caucasian man presented with sudden onset of left sided
hemiparesis and sensory change, right sided headache, diplopia and confusion. The patient was initially treated as a
stroke but was eventually found to have pulmonary and cerebral Nocardia abscesses secondary to a new diagnosis
of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome.
Conclusion: Human Immunodeficiency Virus infection can produce a variety of neurological presentations with the
added possibility of multiple pathological processes being present simultaneously. This is only further complicated
in instances, such as the present case, when Human Immunodeficiency Virus infection has not yet been diagnosed.
It is therefore imperative that appropriate neuroimaging is done at an early stage to ensure timely initiation of
appropriate therapy. Cerebral Nocardia abscesses are a serious and potentially life threatening complication of
Human Immunodeficiency Virus.
Keywords: Human Immunodeficiency Virus, Acquired Immune Deficiency Syndrome, Opportunistic, Nocardia,
Abscess, Stroke

Background
Immunosuppression secondary to Human Immunodeficiency Virus (HIV) can predispose to opportunistic infections of the central nervous system (CNS). Many such
CNS infections are Acquired Immune Deficiency
Syndrome (AIDS)-defining illnesses and include toxoplasmosis, cryptococcal meningitis, tuberculosis, cytomegalovirus and Progressive Multifocal Leukoencephalopathy
(PML) secondary to JC virus reactivation [1]. Nocardia is a
gram positive bacterium that predominantly infects immunocompromised hosts and affects both pulmonary and
extra-pulmonary sites, but is relatively rarer than PML,
toxoplasmosis and cryptococcal meningitis as a cause of
opportunistic CNS infections in HIV/AIDS [2]. In a 1994
Correspondence: james.stefaniak@nhs.net
University of Cambridge School of Clinical Medicine, Cambridge, UK

case series of thirty patients with nocardiosis in HIV/AIDS
only one patient over a four year period had simultaneous
pulmonary and extra-pulmonary nocardiosis [3]. Indeed,
the present authors could only find one case report of
intracranial nocardiosis in the setting of AIDS published
in the past decade in which a man with previously diagnosed HIV presented with amnesia, weakness, headaches
and fever and was found to have multiple ring enhancing
lesions in his frontoparietal cortices bilaterally [4]. Indeed,
many CNS opportunistic infections present with similarly
non-specific features such as fever, confusion and lethargy.
Such non-specific presentations can delay recognition and
appropriate treatment, particularly in patients with undiagnosed HIV/AIDS. Furthermore, there are multiple differentials of cerebral ring enhancing lesions in HIV/AIDS
including toxoplasmosis, tuberculosis, fungal abscess and
primary CNS lymphoma [5]; definitive diagnosis relies on

© 2015 Stefaniak. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Stefaniak BMC Neurology (2015) 15:183

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biopsy, and so consideration of Nocardia in the initial
differential diagnosis is essential to prevent delays in
initiation of treatment for this rare but potentially fatal
CNS infection.
The present article reports the case of a previously well
59 year old man presenting with sudden onset of left sided
hemiparesis and sensory change, right sided headache,
diplopia and confusion who was initially treated as a
stroke but was eventually found to have pulmonary and
cerebral Nocardia abscesses secondary to a new diagnosis
of HIV/AIDS. This is the only case report in the literature
to describe a first presentation of HIV as cerebral
Nocardia abscesses that were initially treated as a stroke.

Case presentation
A 59 year old Caucasian retired sailor with past medical
history notable only for hypertension, who was not on
regular medication and who had a significant alcohol
and smoking history was admitted to the emergency
department. He described sudden onset left arm and leg
weakness 6 days previously with ‘pins and needles’ and a
‘dragging’ sensation in his left leg for 3 days and right
sided headache for 5 days that was sharp, constant, kept
him awake at night and was worse in the morning and
on coughing. He also complained of recent onset diplopia and an episode of fever (self measured temperature
39 °C) 7 days before admission.
On examination he was confused with weakness (Medical
Research Council [MRC] power 3/5), drift, mild spasticity
and numbness to light touch throughout his left arm and
leg. The left knee was hyperreflexic and his left Babinski
reflex was positive. His gait was ataxic.
Admission blood results demonstrated a mild macrocytosis (Mean Cell Volume [MCV] 105 fL), neutrophilia
(neutrophil count 12 x 109/L), lymphopenia (lymphocyte
count 0.39 x 109/L) and hyponatremia (sodium 130 millimolar (mM). An initial non-contrast Computed
Tomography (CT) head (see Fig. 1) showed scattered
areas of hypodensity involving grey and white matter
in the left cerebellar hemisphere, right basal ganglia,
bilateral frontal lobes, bilateral parietal lobes and left
occipital lobe. Ventricles were undistended and undisplaced, no mass or haemorrhage was seen and the
images were reported as being consistent with multiple ischaemic infarcts. The patient was diagnosed as
having a stroke with a National Institute of Health Stroke
Score (NIHSS) of 3 and started on aspirin, a statin and an
angiotensin converting enzyme (ACE) inhibitor.
On day 2 of admission the non-contrast CT head report was revised as being suggestive of metastatic lesions
with surrounding oedema, raising the possibility of cerebral metastases. It was noted that the hypodensities on
the non-contrast CT head demonstrated cortical sparing
and were not wedge shaped, suggesting against multiple

Fig. 1 Non-contrast Computed Tomography head. Non-contrast
Computed Tomography head taken on admission showing scattered
areas of hypodensity involving grey and white matter in the right
basal ganglia, bilateral frontal lobes (see arrow) and bilateral
parietal lobes

lacunar infarcts. A CT-chest, abdomen and pelvis and a
CT head with contrast were requested for staging of the
presumed tumour, and dexamethasone was started for presumed symptomatic cerebral metastases with oedema. Due
to patient confusion, this imaging was only obtained whilst
anaesthetised on day 6 of admission. The CT head with
contrast (see Fig. 2) showed the aforementioned hypodensities to be multiple ring enhancing lesions with surrounding
oedema; additional lesions were noted in the brainstem,
and the largest lesion was in the right frontal lobe measuring 22 mm in diameter. It was reported that appearances
were consistent with disseminated brain metastases but
that intracerebral tuberculomas could give a similar appearance. The CT-chest, abdomen and pelvis showed left upper
lobe consolidation suggestive of infection, with no evidence
of metastases, primary tumour or adenopathy. Blood tests
for tumour markers alpha-fetoprotein, cancer antigen 19–9
(CA19-9), carcinoembryonic antigen (CEA) and prostate
specific antigen (PSA) were all within normal limits.
Prophylactic levetiracetam was started.
A Diffusion Weighted Image-Magnetic Resonance Image
(DWI-MRI) with contrast was subsequently obtained (see
Fig. 3). This showed multiple lesions with restricted diffusion consistent with multiple abscesses and developing
hydrocephalus. A HIV test was requested; serology was
positive for HIV-1, HIV-1 ribonucleic acid (RNA) was detected on polymerase chain reaction (PCR) and the patient’s

Stefaniak BMC Neurology (2015) 15:183

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was started on Highly Active Antiretroviral Therapy
(HAART) for HIV and cotrimoxazole for pulmonary
and cerebral nocardiosis. An External Ventricular Drain
(EVD) was inserted due to hydrocephalus; acute bilateral
frontal lobe haemorrhages with intraventricular extension
on the left were noted on a repeat CT head following
neurosurgery. The patient had neurosurgical burr holes
and was cared for on a neuro-intensive treatment unit
(ITU) for several weeks, but eventually recovered and was
discharged. Follow up CT head showed a reduction in size
of the previous haematoma, decreased size of abscesses
and no hydrocephalus.

Fig. 2 Computed Tomography head with contrast. Computed
Tomography head with contrast showing multiple ring enhancing
lesions with surrounding oedema (see arrows)

CD4 T cell count was 50/mm3. A stereotactic biopsy of the
right frontal lobe abscess was performed; PCR of the aspirate demonstrated the presence of Nocardia. PCR on a
subsequent Broncho-Alveolar Lavage (BAL) confirmed a
diagnosis of pulmonary and cerebral Nocardia. The patient

Fig. 3 Diffusion Weighted Image-Magnetic Resonance Image. A
Diffusion Weighted Magnetic Resonance Image showing multiple
lesions with restricted diffusion (see arrows) consistent with multiple
abscesses and developing hydrocephalus

Discussion
HIV infection can produce a variety of neurological presentations at all stages of the illness, with the added possibility of multiple pathological processes being present
simultaneously. As well as predisposing to atypical CNS
infections, HIV itself can cause HIV-associated dementia,
vacuolar myelopathy, distal sensory peripheral neuropathy,
mononeuritis multiplex and polymyositis. Combining this
with potential side effects of antiretroviral drugs leads to a
diagnostic challenge that is only further complicated in
instances, such as the present case, when HIV infection
has not yet been diagnosed. It is therefore imperative that
appropriate imaging is done at an early stage to ensure
timely initiation of appropriate therapy. Non-contrast CT
heads often have poor specificity in diagnosing intracranial
abscesses; even ring-enhancing lesions on contrastenhanced CT head images have a wide differential diagnosis, including toxoplasmosis, tuberculosis, bacterial and
fungal abscess, primary CNS lymphoma and solid tumour
metastases with surrounding oedema [5]. It was only after
diffusion weighted MRI that intracranial abscesses were
thought to be the most likely pathology in the present
patient and thus a cause for probable immunosuppression
was sought; this was because diffusion restriction favours
a diagnosis of intracranial abscess [4]. Definitive diagnosis
inevitably requires biopsy of the lesion in question. Whilst
Nocardia has historically been diagnosed using conventional culturing techniques [6], validated PCR tests have
been developed to rapidly diagnose Nocardia species in
tissue samples [6], thus enabling more rapid initiation of
definitive therapy. However, it should be borne in mind
that up to 15 % of CNS opportunistic infections in HIV/
AIDS involve multiple concurrent processes [1]; a failure
to respond adequately to definitive therapy should therefore merit further investigations for the possibility of
comorbid CNS infections.
Conclusions
This report describes a case of pulmonary and cerebral
Nocardia abscesses secondary to undiagnosed HIV/AIDS
that presented with clinical signs of a stroke. This highlights

Stefaniak BMC Neurology (2015) 15:183

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the variety of possible neurological presentations of HIV/
AIDS and the appropriate investigations and management
of cerebral abscesses.

Consent
Written informed consent was obtained from the patient
for publication of this Case Report and any accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Ethics

Ethical approval was not required for this Case Report.
Abbreviations
HIV: Human Immunodeficiency Virus; CNS: Central Nervous System;
AIDS: Acquired Immune Deficiency Syndrome; PML: Progressive Multifocal
Leukoencephalopathy; MRC: Medical Research Council; MCV: Mean Cell
Volume; mM: Millimolar; CT: Computed Tomography; NIHSS: National
Institute of Health Stroke Score; ACE: Angiotensin converting enzyme;
CEA: Cancer antigen 19–9, CA19-9 carcinoembryonic antigen; PSA: Prostate
specific antigen; DWI: Diffusion Weighted Image; MRI: Magnetic Resonance
Image; RNA: Ribonucleic acid; PCR: Polymerase chain reaction; BAL: BronchoAlveolar Lavage; HAART: Highly Active Antiretroviral Therapy; EVD: External
Ventricular Drain; ITU: Intensive treatment unit.
Competing interests
The author declares that he has no competing interests.
Authors’ contributions
JS researched, planned and wrote the article.
Authors’ information
JS MA BM BCh
Acknowledgements
I would like to thank cooperation from the patient.
Received: 5 August 2015 Accepted: 23 September 2015

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