Any risk of strain was cultured on blood agr plate for 24?h at 37?C

Any risk of strain was cultured on blood agr plate for 24?h at 37?C. abscess. However, fever persisted and consciousness level deteriorated. Drainage of brain abscess was performed; based on the Gram stain and Kinyoun acid-fast stain, disseminated nocardiosis was diagnosed. Voriconazole was then shifter to trimethoprim/sulfamethoxazole. The presence of was confirmed by the 16S rRNA gene sequence. Treatment course was continued; BDG level normalized after 1?month and cranial MRI showed almost complete improvement after 2?months. Conclusion BDG assay is widely used to diagnose invasive fungal F3 infection; therefore, clinicians should be aware that species may show cross-reactivity with BDG assay on serum. species is a gram-positive, branching, filamentous bacillus that may cause localized and disseminated infections in humans, including pulmonary infection, subcutaneous infection, brain abscess, and bacteremia. -D-glucan (BDG) is a polysaccharide glucose polymer that is found in a broad range of fungal agents, but not in the cell wall of species. Therefore, BDG is not thought to be useful in diagnosing nocardiosis. However, Koncan et al. reported a case of brain abscess that showed elevated level of BDG on cerebrospinal fluid [1]. They also described that species showed cross-reactivity with BDG assay. Here, we presented the first reported case of nocardial infection with elevated serum BDG level. Case presentation A 73-year-old man, Asian, and ex-smoker presented to our department with complaints of fever, headache and appetite loss after 10?months of steroid and immunosuppressive therapy for cryptogenic organizing pneumonia. Physical examination revealed a heart rate of 88 beats/min, blood pressure of 142/74?mmHg, respiratory rate of 20 breaths/min, temperature of 38.5?C, and oxygen saturation of 95% on room air. Chest examination revealed coarse crackles on right lower lung field. Chest radiograph and computed tomography showed infiltrates on the right middle lobe (Figs. ?(Figs.11 and ?and2).2). The white blood cell count, C-reactive protein, and procalcitonin levels were 15,100 /l, 5.73?mg/dl, and 0.221?ng/ml, respectively. Test for human immunodeficiency virus (HIV) infection was negative. Expectorated sputum smears were negative for bacteria and acid-fast bacilli. Urinary antigen test (Binax NOW; Binax, Inc., Portland, ME) for and were negative. Although it was difficult to determine the causative bacteria, a presumptive diagnosis of community-acquired pneumonia was made, and treatment with ampicillin/sulbactam (ABPC/SBT) 1.5?g intravenously every 6?h was initiated. On day 8, white blood cell count normalized and chest radiograph showed improvement; FG-2216 however, fever persisted. Due to a suspicion of drug fever, ABPC/SBT was discontinued. However, fever persisted even after 4?days of ABPC/SBT discontinuation. To search for the source of infection, cranial magnetic resonance imaging (MRI) was done and showed multiple masses (Fig. ?(Fig.3);3); brain abscess was diagnosed. Serum Quantiferon test (QuantiFERON-TB Gold In-Tube; Cellestis, Chadstone, Australia), cryptococcus antigen and toxoplasma antibody were negative. Galactomannan (Platelia Aspergillus Ag; Bio-Rad, Marnes-la-Coquette, France) and -D-glucan (Wako; Wako Pure Chemical Industries, Ltd., Tokyo, Japan) were elevated at 0.6 index, and 94.7?pg/ml, respectively. On day 11, voriconazole (VRCZ) 200?mg intravenously every 12?h was initiated for presumed aspergillus brain abscess. However, after 5?days of treatment, fever continued and consciousness level deteriorated. On day 16, drainage of brain abscess was performed; Gram stain revealed many neutrophils and gram-positive rods with branching, filamentous hyphae (Fig. ?(Fig.4a).4a). Kinyoun acid-fast stain of the gram-positive rods was positive (Fig. ?(Fig.4b).4b). On the basis of these findings, disseminated FG-2216 nocardiosis was diagnosed, and VRCZ was shifted to intravenous trimethoprim/sulfamethoxazole (TMP/SMX) 240?mg/1200?mg every 8?h. The cultured strain was sent to Department of Laboratory medicine of Nagasaki University Hospital, where FG-2216 the presence of was confirmed by 16S rRNA gene sequence. Treatment course was FG-2216 continued. BDG level normalized after 1?month, therefore intravenous TMP/SMX was shifted to oral TMP/SMX 240?mg/1200?mg every 8?h. Cranial MRI showed almost complete improvement after 2?months. Unfortunately, the patient died from aspiration pneumonia after 6?months of treatment. Open in a separate window Fig. 1 Chest radiography on admission showed.