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Clinical Pathologic Conference |

An Independent Elderly Woman With Rapid Onset of Coma

Jindong Xu, MD, PhD1; Anthony T. Yachnis, MD, MS2; Irene Malaty, MD1
[+] Author Affiliations
1Department of Neurology, University of Florida, Gainesville
2Department of Pathology, University of Florida, Gainesville
JAMA Neurol. 2014;71(8):1043-1047. doi:10.1001/jamaneurol.2014.449.
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A 75-year-old woman was transferred from a local hospital because of rapid progression to coma preceded by lower back pain and recurrent falls. Cerebrospinal fluid analysis at the local hospital revealed increased protein with a slightly elevated white blood cell count. Our imaging studies revealed multiple punctate foci with nodular enhancement in the brain and multifocal cystic lesions on the chest and abdomen. The patient was empirically treated with antibiotics and corticosteroids without improvement. She died 3 days after transfer, and autopsy was performed. The differential diagnosis, pathologic findings, and final diagnosis are discussed.

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Figure 1.
Imaging Studies

Magnetic resonance images of the brain with contrast reveal multiple punctate foci of nodular enhancement within the cerebellum (A-C, yellow arrowheads) and leptomeninges in the posterior fossa (C, blue arrowhead), brainstem (D and E, arrowheads), and left occipital lobe (F, arrowheads). Computed tomogram of the chest with contrast reveals mediastinal lymphadenopathy, pleural effusion, and cavitary nodular opacities in the right lower lung (G, arrowheads). Computed tomogram of the abdomen with contrast reveals a cystic lesion on the left kidney (H, arrowhead).

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Figure 2.
Neuropathologic Findings

Coronal section of the cerebral hemisphere revealed numerous punctate lesions located mainly between the cerebral cortex and subcortical white matter (A, arrowheads). Hematoxylin-eosin stain revealed well-circumscribed foci of acute inflammation consistent with microabscesses, the typical lesions of Nocardia infection (original magnification ×250) (B). Grocott methenamine silver stain revealed numerous organisms with a filamentous branching rod appearance within the microabscess (original magnification ×1000) (C).

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