Brain Abscess Caused by Nocardia sp. in an HIV Patient: A Case Report Highlighting Challenges and Treatment Success

Background: Nocardia brain abscess is a rare opportunistic infection in people living with HIV at an advanced stage. Immunosuppression, especially with very low CD4 counts and non-adherence to treatment, increases the risk. These infections are diagnostically challenging due to their nonspecific presentation and the limited sensitivity of routine molecular panels in detecting Nocardia. Case presentation: We present a 57-year-old HIV-positive female who developed a brain abscess after discontinuing antiretroviral therapy (ART) in 2019. She presented in 2023 with progressive headaches, fever, and vomiting. MRI revealed a ring-enhancing lesion, suggesting a brain tumor or severe infection. Craniotomy with pus aspiration confirmed Nocardia sp. The patient was treated with trimethoprim/sulfamethoxazole (TMP-SMX) and imipenem-cilastatin, showing sig-nificant improvement after two weeks of intravenous therapy. The patient was then discharged on oral TMP-SMX. Conclusion: This case highlights the diagnostic challenges of nocardial brain abscesses in pa-tients with HIV and highlights the importance of diagnosis, early neurosurgical intervention, and targeted antimicrobial therapy in improving outcomes.