Multifocal Myoclonus Induced by Trimethoprim–Sulfamethoxazole Therapy in a Patient with Nocardia Infection

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Abstract
A 63-year-old woman with a history of non-Hodgkin's lymphoma that had been treated 25 years previously, as well as a history of hypertension, hypercholesterolemia, transient ischemic attack, and acute myelogenous leukemia with induction of remission three months previously, was admitted to our hospital with a five-day history of fever, fatigue, decreased appetite, and leukocytosis (white-cell count, 18,000 per cubic millimeter), without evidence of a recurrence of leukemia. Blood cultures grew Nocardia asteroides. The patient had no skin lesions or new focal neurologic signs. A computed tomographic scan of the chest revealed multiple new bilateral nodules. The patient refused bronchoscopy. Sputum cultures were negative for fungus. Magnetic resonance images (MRI) of the brain showed extensive, bilateral small-vessel disease without acute infarction. She was started on a regimen of 20 mg of trimethoprim per kilogram of body weight per day and 100 mg of sulfamethoxazole per kilogram per day, given intravenously in two doses, and 2 g of ceftriaxone given twice daily.