
==== Front
BMC Neurol
BMC Neurol
BMC Neurology
1471-2377
BioMed Central London

3826
10.1186/s12883-024-03826-6
Case Report
Brain abscesses: the first report of disseminated Nocardia beijingensis infection in an immunocompetent individual in China
Jin Lihong 123
Zhang Weiqun 2
Su Fang 3
Ji Youqi 13
Ge Yumei 11218070@zju.edu.cn

34
1 https://ror.org/04epb4p87 grid.268505.c 0000 0000 8744 8924 School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053 China
2 Department of Clinical Laboratory, The First People’s Hosiptal of Lin’an District, Hangzhou, Zhejiang 311399 China
3 grid.506977.a 0000 0004 1757 7957 Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang 310014 China
4 Key Laboratory of Biomarkers and In Vitro Diagnosis Translation of Zhejiang Province, Hangzhou, Zhejiang 310053 China
13 9 2024
13 9 2024
2024
24 34120 2 2024
26 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Nocardia is widely distributed in the natural environment and typically cause opportunistic infections. However, it is important to note that the pathogenicity of different Nocardia species may vary significantly. Here we reported the first case of brain abscess caused by Nocardia beijingensis (N. beijingensis) infection in China. A 70-year-old male immunocompetent individual came to our hospital for treatment due to headache. After examination, it was found that he had a brain abscess caused by N. beijingensis. By utilizing a combination of surgical intervention and antibiotic therapy, the patient ultimately achieved full recovery. In addition, we isolated this strain and displayed its ultrastructure through scanning electron microscopy. The phylogenetic tree was analyzed by 16 S rRNA sequence. A literature review of N. beijingensis infections in all immunocompetent and immunocompromised patients was presented. It highlighted that abscess formation appears to be a common manifestation of N. beijingensis infection, and N. beijingensis has become an emerging pathogen in immunocompetent individuals.

Keywords

Brain abscess
Immunocompetent
Infection
Nocardia beijingensis (N. beijingensis)
Phylogenetic tree
New Project of Zhejiang Provincial People’s Hospital entitled "Construction of Rapid Nucleic Acid Detection Platform for Invasive Fungi"20211214 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Brain abscess is characterized as inflammatory lesions, and it is usually caused by pathogens encrust pus on the central nervous system [1, 2], with a mortality rate of approximately 50–55% [3, 4]. In all intracranial space-occupying lesions, the proportion of brain abscesses is nearly 1–2% in developed countries and about 8% in developing countries [4]. According to a survey in northern Europe, the incidence of brain abscesses is 9 cases per million people every year, and it has been rising continuously in recent years [5]. Although Nocardia brain abscess is uncommon and estimated about 1–2% of all intracranial space-occupying lesions, it has the highest mortality rates of all bacterial brain abscesses, which has gradually raised widespread concern [6].

Brain abscess caused by Nocardia infection is characterized by cerebritis and central focal necrosis. Nocardia are aerobic actinomycetes ubiquitous in water and soil, which can cause local or disseminated infections primarily affecting immunocompromised patients such as AIDS, malignant neoplasms, hematopoietic stem cells or organ transplantation, diabetes, COPD, flora imbalance, chronic kidney disease, trauma [7]. To date, nearly 92 Nocardia species have been identified, of which 54 have been identified as clinically significant pathogens [8–10].

Nocardia beijingensis (N. beijingensis) was initially isolated from sewage ditch soil in Beijing, the capital of China in 2001 by Wang et al. and was first reported as a human pathogenic pathogen primarily affecting immunocompromised patients in Thailand and Japan in 2004 [11, 12]. Here we reported the first case of brain abscess caused by N. beijingensis infection in China, which could raise the awareness of disseminated nocardiosis in immunocompetent individuals.

Case presentation

Clinical feature

A 70s male patient presented intermittent bilateral frontal headaches, swelling, fatigue, and unsteady gait, without any apparent causes 10 days ago. He had previously sought medical attention at a local hospital where a cranial Computed Tomography (CT) scan revealed extensive areas of low density in the left hemisphere of the cerebellum, as well as old lacunar infarcts in both basal ganglia and periventricular regions. Enhanced Magnetic Resonance Imaging (MRI) suggested a nodular lesion in the left cerebellar hemisphere, raising suspicion of a tumor with associated hemorrhage. The patient received treatment for a period of time but the efficacy was not good, so he came to our hospital for further treatment. Reviewing the medical records, a personal history of cerebral infarction was noted, without any other underlying conditions or medication use. After admission, the patient underwent a physical examination, with a body temperature of 36.8 ℃, blood pressure of 118/78 mmHg, clear consciousness, soft mind, and fluent language. Bilateral pupils were equally large and round, with a left to right ratio of 2.5:2.5 mm. He was sensitive to light reflection and had normal eye movements. Bilateral facial patterns were symmetrical, and the facial sensation was symmetrical on both sides. The pharyngeal reflex existed. The muscle strength of the limbs was at level V, with normal muscle tone and normal tendon reflexes. The superficial sensation of the limbs was symmetrical on both sides, and the deep sensation was basically normal. Due to concerns about intracranial infection, in addition to blood tests, we also extracted cerebrospinal fluid from the patient for testing. The laboratory results were shown in Table 1, where the patient’s blood infectivity indicators were elevated and abnormal cerebrospinal fluid indicators indicated the presence of intracranial infection.

Table 1 Laboratory examination results of the patient

Laboratory indicators	Result	Reference range	
White blood cell count	12.83 × 109/L	3.50-9.50 × 109/L	
C-reactive protein	42.4 mg/L	≤ 10.0 mg/L	
Serum total protein	60.1 g/L	65.0–85.0 g/L	
Serum albumin	34.9 g/L	40.0–55.0 g/L	
Osmotic pressure	273 mosm/L	275–300 mosm/L	
Pan’s test (CSF)	Positive	Negative	
Protein quantification (CSF)	108.3 mg/dl	≤ 45.0 mg/dl	
Glucose quantification (CSF)	5.45 mmol/L	2.50–4.50 mmol/L	
Abbreviations Cerebrospinal fluid (CSF)

Imaging examination

Upon admission, the patient underwent cranial MRI examination, which revealed bilaterally scattered patchy and focal abnormal signals in the frontal and parietal white matter, periventricular region, and basal ganglia. These signals appeared confluent in some localized areas. On T1-weighted imaging (T1WI), the signals were slightly decreased or isointense, while on T2-weighted imaging (T2WI) and FLAIR imaging, the signals were increased. No apparent diffusion restriction was observed on diffusion-weighted imaging (DWI). A lesion was observed in the left cerebellar hemisphere, characterized by indistinct borders. T1WI showed slightly decreased signals, while T2WI, FLAIR, and DWI showed high signals. Additionally, the surrounding area exhibited edema. In Fig. 1A, a distinct abscess lesion was seen, suggesting the possibility of an infection. Figure 1B and C depict postoperative MRI images acquired immediately after surgery and two weeks post-surgery, respectively. These images demonstrate the changes following the left cerebellar lesion resection, gradual resorption of pneumocephalus in the surgical area, and a reduced range of multiple enhancing lesions in the left cerebellum compared to the previous scan.

Fig. 1 MRI images of the patient’s head. (A) MRI images of the patient upon admission. (B) MRI images of the patient after surgery. (C) MRI images of the patient two weeks after surgery. The locations of Abscess lesions were indicated by the red arrow

Etiological examination

During the excision of cerebellar lesion, a large abscess was identified in the left cerebellar hemisphere and promptly sent for examination. Histopathological analysis (Fig. 2A) revealed the presence of suppurative inflammation with abscess formation. Microscopic examination of the smears (Fig. 2B) revealed clusters of Gram-positive bacteria, while acid-fast staining (Fig. 2C) demonstrated red-colored bacterial filaments. Scanning electron microscopy (Fig. 2D) revealed rough, long, filamentous bacteria. After three days of incubation, blood agar plate culture exhibited white, dry, wrinkled colonies, which were identified as N. beijingensis by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, Hangzhou YiDan biology technology co., ltd) (Fig. 2E). The antibiotic susceptibility results were summarized in Table 2.

Fig. 2 Patient’s etiological results. (A) HE staining section of the patient’s abscess tissue showed inflammatory infiltration. (B) Gram staining of abscess tissue revealed purple bacterial clusters. (C) The abscess tissue was positive for acid fast staining, with visible red hyphae. (D) Under the electron microscope, slender bacterial bodies could be seen in N. beijingensis ZJSRMYY1. (E) Identification peak diagram of N. beijingensis ZJSRMYY1 by mass spectrometry

Table 2 Drug sensitivity results of the N. beijingensis ZJSRMYY1

Antibiotic	Method	Result	Break	Sensitivity level	
Imipenem	Etest	0.25 µg/mL	1–4	S	
Amoxicillin-clavulanate	Etest	16 µg /mL	8–32	I	
Ceftriaxone	KB	36 mm	19–23	S	
Vancomycin	Etest	128 µg/mL	4–32	R	
linezolid	Etest	2 µg/mL	4–8	S	
Levofloxacin	Etest	1 µg/mL	0.5-2	I	
Meropenem	Etest	0.5 µg/mL	1–4	S	
TMP-SMZ	Etest	0.0032/0.0608 µg/mL	2–4	S	
E-test: Epsilometer test; KB: Kirby-Bauer method; TMP-SMZ: Compound sulfamethoxazole. S: Sensitive; I: intermediate; R: Resistant

Treatment and outcome

During the patient’s hospitalization, continuous mannitol was administered to reduce intracranial pressure. On the second day of hospitalization, brain MRI revealed the presence of abscess. A single dose of vancomycin was administered for antimicrobial therapy. On the fifth day, the patient underwent cerebellar lesion resection. Following the incision of the left cerebellar hemisphere, purulent fluid was observed to discharge from a location approximately 2 cm deep to the left midline. After closure of the breach, the edematous area around the abscess was dissected, and a large abscess was completely excised for pathological and pathogen examinations. Based on the preoperative magnetic resonance images, the lateral part of the cerebellum was partially resected, and the remaining infected tissue was removed. The surgical field was thoroughly irrigated with a saline solution containing vancomycin, adequate hemostasis was achieved, and a gelatin sponge adhered to the surgical site was used to prevent further bleeding. After ensuring no active bleeding, dural defects were repaired with artificial dura mater, fascia was reconstructed, the bone flap was repositioned, and fixation was performed with titanium screws and plates. Layered closure was achieved with subcutaneous and skin sutures. Postoperatively, the patient received a combination of vancomycin, meropenem, linezolid, and trimethoprim-sulfamethoxazole (TMP-SMX) for antimicrobial therapy. After 24 days, the patient’s infection markers decreased to normal levels, the brain lesion on the MRI diminished, and the patient remained stable, allowing for discharge. Following discharge, the patient continued oral administration of linezolid and sulfamethoxazole/trimethoprim for 30 days. The treatment plan for the patient was presented in Fig. 3

Fig. 3 Treatment timeline

Phylogenetic tree of N. beijingensis ZJPPH1

The nucleotide sequences of the1540-bp 16 S rRNA were verified and utilized to perform phylogenetic analysis by the Molecular Evolutionary Genetics Analysis (MEGA) software version 11 through the minimum-evolution method. A phylogenetic tree was constructed utilizing the sequence of N. beijingensis ZJPPH1 (GenBank number: PP267164) from the isolate of this study along with 29 available sequences with the highest homology retrieved from GenBank. The nucleic acid sequence of the present isolate revealed 99.37% similarity with N. beijingensis strain IFM 0841 (Fig. 4).

Fig. 4 Phylogenetic tree of N. beijingensis ZJPPH1

Discussion

Brain abscess is a life-threatening infection, and the mortality rate increases with prolonged illness [5]. Approximately 70% of surviving patients will experience sequelae such as epilepsy or neurological deficits [13]. Generally speaking, head trauma, chronic ear infections, dental infections, and immune dysfunction are the main risk factors for brain abscess, but the possibility of infection without obvious causes cannot be ruled out [14]. Oral bacteria such as Streptococcus anginosus, Fusobacterium species and Aggregatibacter species are the most common bacteria that cause brain abscess. Brain abscess caused by Staphylococcus aureus and other Gram-negative bacteria are relatively rare but have a poor prognosis for patients. Mycobacterium tuberculosis has regional prevalence, while brain abscesses caused by other fungi, parasites, and Nocardia are more common in immunocompromised patients [15].

Nocardia was first described as a saprophyte and innocuous species widely distributed in soil, water, and decaying plants. In recent years, more and more clinical data showed that some Nocardia species might cause life-threatening infections with varying pathogenicity, antibiotic resistance and prevalence. Nocardia abscessus, Nocardia cyriacigeorgica, Nocardia farcinica, and Nocardia nova commonly caused pulmonary infections, while Nocardia brasiliensis was often associated with cutaneous infections [16, 17]. Infections in other sites were typically caused by traumatic inoculation and hematogenous spread from primary foci [16]. Currently, there is extremely limited information on the epidemiology of N. beijingensis infection. According to the literature collected by N. beijingensis on Pubmed retrieval platform and the nucleic acid sequence source of N. beijingensis isolates published on Genbank, it has a global popularity with higher prevalence in Japan, USA, France, Mexico, Costa Rica, KSA, China, Thailand, Italy, Israel, Colombia, Australia. Worryingly, the number of immunocompetent patients with N. beijingensis is as high as 35.71% (10/28). A total of 28 cases of N. beijingensis infection were reported in the world, including 18 cases in immunocompromised patients (3 cases with diabetes, 1 case with smoking, 8 cases with HIV, 3 cases with solid organ transplantation, 6 cases with immunosuppressive drug, 2 cases with autoimmune diseases, and 1 case with malignant tumor), and 10 cases in immunocompetent individuals (Table 3). The average age of cases of N. beijingensis nocardiosis was 52-years-old, with a higher prevalence in males than females. Neurological infections accounted for 11 cases (39%), followed by pulmonary infections in 10 cases (36%), skin infections in 2 cases (7%), and 1 case each in other sites (including thoracic cavity, kidneys, heart, and the erector spinae muscle) (4%). Regarding N. beijingensis, based on existing case reports, despite variations in the site of infection, these cases share a common feature - the formation of abscesses at the lesion site [18, 19]. This appears to be a distinguishing characteristic of N. beijingensis infection.

Table 3 Reported cases of N. beijingensis in immunocompetent and immunocompromised patients

Year	Country	Age	Gender	Organ involved	Immunodeficiency factors	Treatment	Outcome	Reference	
2020	USA	57	Female	Intracranial	-	TMP/SMX, intravenous injection/15 mg/kg/8 h/6 weeks;

TMP/SMX oral/160/800 mg/8 h/12 months

	Rehabilitation	Roy et al. [23]	
2021	USA	47	Male	Lung	-	Imipenem/cilastin and TMP/SMX, intravenous;

TMP/SMX and doxycycline, oral

	Rehabilitation	Raslan et al. [24]	
2023	China	57	Female	Chest	-	Surgical removal of abscess;

TMP/SMX, 15 months

	Rehabilitation	Qi et al. [25]	
2020	Japan	68	Male	Intracranial	-	Meropenem and TMP/SMX;

TMP/SMX, 7 months

	Relieve symptoms and transfer to long-term care	Tanaka et al. [26]	
2015	Italy	75	-	Spinal	-	Imipenem and amikacin, 3 weeks;

TMP/SMX, 3 months

	Rehabilitation	Rigotti et al. [27]	
2015	Israel	55	Female	Lung	-	Prednisone 30 mg daily, 21 days; TMP/SMX, oral/3 months;

Ceftriaxone, intravenous/1 month

	Rehabilitation	Abdel-Rahman et al. [28]	
2021	USA	58	Male	Intracranial	-	TMP-SMX and ceftriaxone, intravenous/8 weeks;

TMP-SMX and azithromycin, oral/1 year

	Septicemia leading to death	Diioia et al. [29]	
2019	Colombia	58	Male	Intracranial	-	1 g meropenem and 15 mg/kg TMP-SMX /amikacin every 8 h	Death from multiple infections	Solano-Varela et al. [30]	
2012	France	42	Male	Lower left leg anterior skin	-	TMP/SMX oral/160/800 mg/ six times daily	Skin lesions subsided; Not followed up	Derancourt et al. [31]	
2014	USA	48	Male	Lung	-	Surgical removal of lesion site; Ceftriaxone, 6 weeks;

TMP/SMX, 6 months

	Rehabilitation	Crozier et al. [22]	
2016	Thailand	59	Male	Intracranial	HIV	TMP/SMX	Rehabilitation	Phoompoung et al. [32]	
2022	USA	57	Male	Left adrenal	Type

2 diabetes

	Surgical removal of lesion site; Linezolid 3 months; TMP-SMX for

7 months

	Rehabilitation	Pender et al. [18]	
2017	Thailand	32	Male	Heart	HIV	TMP/SMX; Imipenem/cilastatin	Infectious shock leading to death	Laksananun et al. [33]	
2017	USA	50	Male	Intracranial	HIV	TMP-SMX and meropenem, 1 year	Take a turn for the better	Keenan et al. [34]	
2023	Mexico	37	Male	Intracranial	HIV	Surgical removal of lesion site; TMP-SMX, and vancomycin, 8 days	Take a turn for the better	Nieves et al. [4]	
2022	Mexico	49	Male	Intracranial	HIV	Imipenem and TMP/SMX intravenously 2 weeks; linezolid and TMP/SMX intravenously 3weeks; Amoxicillin/clavulanic acid and

TMP/SMX 1 year

	Rehabilitation	Leon-Tavares et al. [35]	
2020	USA	45	Male	Intracranial	HIV	TMP/SMX, imipenem, and amikacin 2 weeks; Oral

minocycline and TMP/SMX

	Take a turn for the better	Bertrán-López et al. [36]	
2014	USA	50	Female	Lung	Type 1 diabetes, solid organ transplantation, immunosuppressant	TMP/SMX 6 months	Take a turn for the better	Aragaki-Nakahodo et al. [37]	
2017	USA	50	Female	Lung	Autoimmune disease, immunosuppressant, smoke	MeropeneM 4 weeks	Take a turn for the better	Sheikh-Taha et al. [38]	
2011	Japan	48	Male	Lung	Solid organ transplantation, immunosuppressant	Imipenem/cilastatin 30 days; Ceftriaxone 12 days; Minocycline 3 months	Take a turn for the better	Ogawa et al. [39]	
2016	USA	52	Female	Eyes	Immunosuppressant	TMP/SMX, amikacin and b/trimethoprim	Take a turn for the better	Gonzalez et al. [40]	
2011	France	47	Male	Lung	HIV	Imipenem and amikacin 3 weeks; TMP/SMX 3 months	Rehabilitation	Martinaud et al. [19]	
2015	Australia	80	Male	Intracranial	Type 2 diabetes	Meropenem, ceftriaxone

and TMP/SMX 1 week; Amikacin

	Take a turn for the better	Angela et al. [41]	
2015	Thailand	58	Male	Psoas muscle	Solid organ transplantation	TMP/SMX and imipenem 2 weeks; TMP/SMX 4 weeks	Take a turn for the better	Palavutitotai et al. [42]	
2011	Japan	79	Male	Skin of left forearm	Malignancy	Garenoxacin 2 weeks	Rehabilitation	Ohmori et al. [43]	
2008	China	13	Female	Lung	SLE, immunosuppressant	Meropenem 4 weeks; TMP/SMX 1 year	Rehabilitation	Chu et al. [44]	
2008	Japan	60	Female	Lung	Immunosuppressant	TMP/SMX, meropenem and levofloxacin	Died of respiratory failure	Takayanagi et al. [45]	
2021	Thailand	35	Female	Lung	HIV	TMP/SMX 3 weeks	Rehabilitation	Kiatsuranon et al. [46]	

The patient we report here had a previously healthy constitution and no smoking history. However, based on the pulmonary CT findings revealing inflammatory infiltrates and multiple small nodules, we suspected that the patient had a pulmonary infection that subsequently disseminated to the central nervous system, causing intracranial infection. Although diabetes, HIV, autoimmune diseases and smoking have been identified as risk factors for N. beijingensis infection, this patient had no documented risk factors, nor any history of immunosuppressive medication [20, 21]. Therefore, prevention of N. beijingensis infection should not be limited to immunocompromised or susceptible individuals. Once patients exhibit clinical manifestations of infection, the possibility of N. beijingensis infection should be considered. In 2014, Crozier et al. reported the first case of N. beijingensis infection in an immunocompetent patient in the United States [22]. Since then, an increasing number of reports have emerged in immunocompetent patients, predominantly involving the lungs and central nervous system [18]. Here we report the first case of brain abscess caused by Nocardia beijingensis infection in China, which develops an awareness of disseminated nocardiosis in immunocompetent individuals.

We reviewed all reported cases of N. beijingensis infection. Given that N. beijingensis infections often lead to the formation of abscesses at the site of infection, surgical intervention and antimicrobial therapy are necessary. Furthermore, susceptibility testing for N. beijingensis is indispensable. Currently, most reports indicate that N. beijingensis is susceptible to TMP-SMX, carbapenems, amikacin, and/or third-generation cephalosporins [22] but resistant to amoxicillin-clavulanic acid and ciprofloxacin according to the reported antimicrobial sensitivity results of N. beijingensis (Table 4), unlike N. transvaalensis is resistant to amikacin and N. abscessus is resistant to imipenem.

Table 4 Summary of reported drug sensitivity results of N. beijingensis

Reported strains	1 [25]	2 [39]	3 [29]	4 [22]	
Antibiotic	MIC (μg/mL)	S/I/R	MIC (μg/mL)	S/I/R	MIC (μg/mL)	S/I/R	MIC (μg/mL)	S/I/R	
Amikacin	< 1	S	-	-	≤ 1	S	≤ 1	S	
Amoxicillin-clavulanic acid	≥ 64/32	R	-	-	64	R	> 64	R	
Ceftriaxone	< 4	S	0.5	S	≤ 4	S	≤ 4	S	
Ciprofloxacin	≥ 4	R	-	-	4	R	4	R	
Clarithromycin	0.5	S	-	-	0.5	S	8	R	
Imipenem	< 2	S	0.5	S	≤ 2	S	≤ 2	S	
Linezolid	< 1	S	-	-	≤ 1	S	2	I	
Minocycline	< 1	S	2	I	2	I	≤ 1	S	
Trimethoprim/sulfamethoxazole	< 0.25/4.75	S	1/19	S	≤ 0.25	S	≤ 0.25/0.1	S	
Tobramycin	< 1	S	-	-	≤ 1	S	≤ 1	S	
Doxycycline	< 0.12	S	-	-	4	I	8	R	
Moxifloxacin	≥ 8	R	-	-	≤ 0.25	S	1	I	

Our susceptibility results showed that the N. beijingensis ZJSRMYY1 strain was sensitive to TMP-SMX, linezolid and amoxicillin-clavulanate, intermediate to levofloxacin, but resistant to vancomycin, which explained the initial ineffectiveness of vancomycin treatment. Following the issuance of susceptibility results, we promptly switched to TMP-SMX and linezolid for treatment. Therefore, susceptibility testing played a crucial role in guiding the choice of antibiotics for Nocardia infections.

In conclusion, we report the first case of an immunocompetent individual who developed a brain abscess due to N. beijingensis infection in China. Abscess formation appears to be a common manifestation of N. beijingensis infection, and N. beijingensis has become an emerging pathogen in immunocompetent individuals. when patients present with symptoms such as headache, particular attention should be given to the possibility of intracranial infection of N. beijingensis. Susceptibility of N. beijingensis is uncertain to amoxicillin-clavulanic acid, ciprofloxacin and levofloxacin, therefore susceptibility testing is necessary in guiding the choice of antibiotics.

Acknowledgements

We thank all members of the microbiology laboratory of Zhejiang Provincial People’s Hospital for their help in the collection of clinical data.

Author contributions

Lihong Jin and Weiqun Zhang analyzed data and draft articles. Fang Su collectd clinical data. Youqi J and Yumei Ge modified the article. All authors reviewed the manuscript.

Funding

This study was supported by the [New Project of Zhejiang Provincial People’s Hospital entitled “Construction of Rapid Nucleic Acid Detection Platform for Invasive Fungi”] under Grant [number 20211214].

Data availability

Data available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

This study was supported by the Ethics Committee of Zhejiang People’s Hospital (Ethics Committee Approval of Biomedical Research Involving Humans, Approval No.: 2022JS008) and was carried out in accordance with the ethical standards of the Declaration of Helsinki.

Consent for publication

Written and informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Lihong Jin and Weiqun Zhang contributed equally to this work.
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