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Bone marrow toxicity and worsening of nocardia infection: case report A man [age at initial reaction onset not stated] developed bone marrow toxicity following treatment with docetaxel and radium-223-chloride for metastatic prostate cancer. At the age of 67 years, he additionally exhibited worsening of Nocardia infection during treatment with dexamethasone for metastatic prostate cancer [dosages and routes not stated; times to reactions onsets not stated]. The man, who had metastatic prostate cancer, presented at the age of 67 years with the complaint of facial numbness, malaise, left leg weakness from the last 1week. He recently received 8 cycle of docetaxel (completed in 2016), two years prior to presentation, and radium-223-chloride [radium 223] for 5 months in 2017, almost 1 year before the presentation and received a treatment response. Prior to the admission, based on the laboratory tests pancytopenia was revealed, which was similar to the bone marrow infiltration and disease progression from his prostate cancer, in combination with possible latent effects of previous marrow toxicity due to docetaxel and radium-223-chloride. Head CT on presentation, revealed two rim-enhancing lesions and MRI brain showed two lesions, one complex multilobulated in the vermis and other in the right parietal lobe, showing restricted diffusion. The lesion was speculated to be intracerebral metastasis secondary to prostate cancer and based on the advanced stage of his cancer he started supportive treatment with dexamethasone 8mg twice daily. However, little symptomatic improvement was achieved. During hospitalisation, he developed several cutaneous lesions including to his right forearm, left forearm, right leg and axilla, which gradually progressed to blood-filled blisters and he developed fever. The incision and drainage of the right forearm lesion and the further culture of the left arm lesion revealed Nocardia farcinica. A repeat MRI of the brain revealed enlargement of the cavitated lesions and appearances now typical of cerebral abscesses, with new lesions found in the right frontoparietal operculum, left temporal lobe and medulla. On further evaluation, the significant progression of the cerebral lesions were observed and cutaneous nocardiosis was confirmed. It was speculated that dexamethasone might have worsened underlying Nocardia infection. The man started treatment with meropenem, cotrimoxazole, amikacin, followed by moxifloxacin. One month later, an improvement in Nocardia infection was noted. A repeat MRI was performed, which showed significant improvement. He was recommended to continue antimicrobials treatment at least for 6 months and for up to 12 months. He was discharged with moxifloxacin and co-trimoxazole therapy, with plan of further follow-up. Livings C, et al. Nocardia farcinica masquerading as intracerebral metastases in advanced metastatic prostatic cancer. BMJ Case Reports 13: 1-4, No. 9, 7 Sep 2020. Available 803506826 from: URL: http://doi.org/10.1136/bcr-2019-233678

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