Objective:

To report a case of disseminated Nocardia farcinica with multiple cerebral abscesses in a patient receiving immunosuppressive therapy for autoimmune hepatitis.

Approach:

• Patient Presentation: A 55-year-old man with autoimmune hepatitis and soil exposure presented with cognitive impairment, dysarthria, and right upper extremity weakness.
• Treatment History: He had received high-dose corticosteroids and azathioprine, with TMP-SMX prophylaxis interrupted 2–4 weeks prior to presentation.
• Diagnostic Findings: Neuroimaging revealed multiple ring-enhancing intracerebral lesions; Nocardia farcinica was confirmed via aspiration and drainage.
• Therapeutic Approach: Antimicrobial therapy was adjusted to imipenem-cilastatin and TMP-SMX based on susceptibility testing.
• Outcome: The patient showed gradual neurological improvement and was discharged to rehabilitation after 18 days.

Key Findings:

• Disseminated nocardiosis should be considered in immunosuppressed patients with neurological decline and ring-enhancing brain lesions.
• Microbiological confirmation of Nocardia farcinica was obtained from two sites.
• Early tissue diagnosis and neurosurgical intervention were critical for the patient's recovery.

Interpretation:

The case highlights the risk of disseminated nocardiosis in patients undergoing immunosuppression and the importance of timely diagnosis and treatment.

Limitations:

• Limited published reports on CNS nocardiosis associated with autoimmune hepatitis.
• The case is based on a single patient experience.

Conclusion:

The case reinforces the need for vigilance regarding opportunistic infections in immunosuppressed patients and the effectiveness of susceptibility-guided therapy.