Malignant Pheochromocytoma with Brain Abscess Inducedby Nocardia Infection after Treatment with Cyclophosphamide (CVD), 5-Fluorouracil (FU) and Carboplatin (CBDCA)

1. Abstract

A 47 years old man who had been diagnosed as malignant pheochromocytoma with metastases of lumbar spines at 21 years old. He had received partial tumor abscission, radiotherapy and 131I-MIBG treatment, He had been suffered from gait disturbance for spinal compression by the metastasis of vertebralspinesat42yearsold.CVDtreatmentand5-FU+CBDCAtreatmenthadbeenperformedfor 13cycles.Aftertreatmentwith5-FUandCBDCA,MRIimagingshowedbrainabscessanddrainage for brain abscess had been done. Nocardiafarcinicawas identified in his brain abscess. Treatment with ST combination vanished brain abscess by MRI imaging

2. Keywords

Malignant pheochromocytoma; Nocardia

3. Introduction

Pheochromocytoma is a catecholamine developing tumor originatedfromchromaffintissue.Extra-adrenaltumorhadbeencalled asparaganglioma.Metastaticmalignantpheochromocytomatoits non-chromaffin tissues was found in 10-35% of paraganglioma. Metastasistothebone,liver,lungs,andlymphnodesidentifiedas nonchromaffin tissues, had been appeared, which was called as malignant pheochromocytoma [1]. CVD treatments (750mg/m2 cyclophosphamide, 1.4mg/m2 vincristine, 600mg/m2 dacarbazine) had been used as general chemotherapy [2, 4]. Serious problem should be pointed out the side effects such as myelosuppression and immunosuppression in spite of a tumor reduction. Nocardia infectionwasappearedintheimmunosuppressionduringanticancertreatments.Nocardiaarehabituallyalivinginsoiland20-30% of pulmonary nocardiosis spreads to the central nervous system. Nocardiosis in the central nervous system had been found as the brain abscess [3]. We have reported a malignant pheochromocytomawithabrainabscesscausedbynocardiosisafterCVD,5-FU andCBDCAtreatments(600mg/m25-FU,180mg/m2 carboplatin).

4. Casepresentation

A 47 years-old man had been diagnosed as malignant pheochromocytomaofrightadrenalglandwiththemetastasisoflumbar 30- 31 years-old. However, there was no reduction of metastatic bone tumor. He had received radiation therapies in the metastatic lesions such as thoracic vertebra, cervical vertebrae, pelvis and lumbosacralspineat35,38,39and40years-old,respectively.He sufferedfromgaitdisturbanceduetospinalcordcompression,and finally anterior and posterior spinal fixation and decompression operationsandalsoradiationtherapieshadbeendoneforcervical metastaticgrowingtumorat42years-old.Moreover,hewastreated with 5 mg prednisolone. At 44 years-old he became quadriplegia and bedridden. After CVD treatments (750mg/m2 cyclophosphamide,1.4mg/m2vincristineand600mg/m2dacarbazine)for13cycles, fortunately, the reduction of metastatic tumor was observed intheearlyperiod.Next,5-FUandCBDCA(600mg/m25-FUand 180mg/m2 carboplatin) medical treatments at 45-47 years-old for 13cyclesmadenoreductionofmetastatictumor.At47years-old, his left homonymous hemianopsia had developed with anorexia for 1 month after treatment with 5-FU and CBDCA. Physicalexaminationsat47yearsoldwereasfollows:Hisheight andweightwere171.2cmand47.1kg(BMI16.1kg/m2 ),respectively.Bodytemperature:36.3℃,bloodpressure:96/54mmHg,and

5. Discussion

Sixty-four percent of the patients with nocardiosis are immunosuppressive. Nocardia infection was due to using glucocorticoid and anticancer agent and having a malignant tumor, transplantation,HIVinfection,anddiabetesmellitus[3].Inthispatient,5-FU and CBDCA medical treatments with CV catheter had caused the riskfactor.Nocardiaisalwayspresentinthesoilinaerobicmycobacterial. The route of infection might be considered from lungs or skin, and 20% of nocardiosis appeared in brain abscess which has been reported as only solitary brain abscess. As the source of infection in this case, infected skin wound in the posterior cervicallesionafterspinalfixationorCVcathetershouldbesuggested. ThetreatmentfornocardiosishasbeenneededforSTcombination therapy which might be maintained at high concentration in central nervous system for at least one year.

6. Conclusion

Here, we presented a case of malignant pheochromocytoma with improvednocardiosisofbraintreatedwithSTcombinationtherapyafteralongtreatmentwith5-FUandCBDCAanti-tumortreatments. We hope to refer these clinical course and treatments for malignant pheochromocytoma and nocardiosis after strong immunosuppressivetreatments.

References

1. Naruse K. Thepointofdiagnosisandtreatmentinpheochromocytoma diagnosis for malignancy. Annual Review diabetes mellitus, metabolism, endocrine 2006 Chugaiigaku Co. 2006; 206-10.

2. AverbuchSD,SteakleyCS,YoungRC,GelmannEP,GoldsteinDS,Stul lR,etal.Malignantpheochromocytoma:effectivetreatmentwith combination of cyclophosphamide, vincristine, and dacarbazine.Ann Intern Med. 1988; 109: 267-73.

3. Ambrosioni J, Lew D, Garbino J. Nocardiosis: Updated ClinicalReviewandExperienceataTertiaryCenter.Infection.2010;38: 89-97.

4. Srimuninnimit V, Wampler GL. Case report of metastatic familialpheochromocytoma treated with cisplatin and 5- fluorouracil.Cancer Chemother Pharmacol. 1991; 28: 217-9.

Citation:

Tiram Y. Malignant Pheochromocytoma with Brain Abscess Inducedby Nocardia Infection after Treatment with Cyclophosphamide (CVD), 5-Fluorouracil (FU) and Carboplatin (CBDCA). Annals of Clinical and Medical Case Reports 2020