Isolated endogenous Nocardia endophthalmitis after immunosuppression
© The Author(s) 2012
Received: 25 October 2011
Accepted: 23 December 2011
Published: 26 January 2012
This study is aimed to report a case of endogenous Nocardia endophthalmitis in the setting of immunosuppression from chronic steroid use.
A case report was conducted.
A 79-year-old woman presented with decreased vision with floaters in the left eye. Ophthalmic examination revealed severe inflammation in the anterior chamber, vitreous opacities, and retinal detachment. Vitreous cultures grew Nocardia farcinica without any systemic foci of infection found during further workup. The patient was treated with intravitreal amikacin and oral trimethoprim-sulfamethoxazole, and her retinal detachment was later repaired in the operating room. The patient has since remained stable with no signs of retinal detachment or active infection.
Nocardia endophthalmitis is a rare, but serious intraocular infection that should be considered in the differential diagnosis in any immunosuppressed patient, including those receiving steroids, who presents with signs of intraocular infection.
KeywordsEndogenous Endophthalmitis Nocardia Immunosuppression Steroids
Nocardia are aerobic, Gram-positive, weakly acid-fast, filamentous bacteria that cause opportunistic infections in immunocompromised patients. Although most commonly seen in the lungs, brain, and other soft tissues, these organisms are rare but significant causes of intraocular infection . Herein, we present a case of endogenous Nocardia endophthalmitis in a patient with giant cell arteritis.
A 79-year-old woman presented complaining of decreased vision with floaters in the left eye for 2 weeks. Past medical history was significant for giant cell arteritis treated with 40 mg/day oral prednisone for 3 months.
The patient was started on intravenous broad-spectrum antibiotics and underwent diagnostic vitrectomy followed by intravitreal injections of vancomycin, ceftazidime, foscarnet, and amphotericin. When vitreous cultures grew Nocardia farcinica, the patient was admitted for further workup. During this admission, the patient remained afebrile and asymptomatic with a normal white blood cell count and negative blood cultures. Further diagnostic workup, including a CT of the chest and an MRI of the brain, did not reveal any lesions suggestive of any systemic source of infection. As such, after receiving a dose of intravitreal amikacin, the patient was discharged on oral trimethoprim-sulfamethoxazole (TMP-SMX) and advised to follow-up in clinic.
Nocardia endophthalmitis is a rare, but serious intraocular infection. It is usually exogenous in origin, occurring after ocular trauma or surgery [2, 3]. Endogenous Nocardia endophthalmitis is more uncommon, occurring in immunocompromised patients as the result of hematogenous dissemination, usually from a primary pulmonary focus [4–6]. Occasionally, this type of endophthalmitis can occur in isolation without a systemic focus of infection; however, this is even more rare with only two reported cases in the literature [7, 8]. Our case is unique in that it is the first reported case of isolated endogenous endophthalmitis caused by N. farcinica in a patient without a clear systemic source, in the setting of immunosuppression from steroid use.
Previous reports have described poor outcomes of nocardial infections that often resulted in enucleation and death from extraocular foci [4–6]. In fact, this is the first report of isolated endogenous Nocardia endophthalmitis within the United States that has not resulted in enucleation . In many of these cases, delays in treatment due to initial misdiagnosis contributed to the morbidity and mortality [4, 6]. Indeed the diagnosis of Nocardia can often be difficult given its nonpathognomonic clinical features and slow growth on culture [1, 6]. As such, it is important that Nocardia be considered in the differential diagnosis in any immunosuppressed patient, including those receiving steroids, who presents with signs of intraocular infection.
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