Subretinal Abscess Due toNocardia farcinicaResistant to Trimethoprim- Sulfamethoxazole in a Patient with Systemic Lupus Erythematosus

Endogenous Nocardial Endophthalmitis Misdiagnosed as Giant Cell Arteritis

Purpose

Endogenous endophthalmitis is uncommon but potentially dangerous. We present a fatal presentation of endogenous Nocardial endophthalmitis in the context of steroid use for treatment of giant cell arteritis.

Case Presentation

An 84-year-old Caucasian female presented to the local emergency room with severe headaches, myalgia and shoulder and calf muscle pain. She was treated for a presumed diagnosis of giant-cell arteritis with corticosteroids and subsequently developed an intense retro-orbital pain in the right eye. Fundus examination revealed a white, vascularized chorioretinal mass at the equator of the eye in the inferotemporal quadrant. Antibiotics were given and a vitrectomy was performed. The culture of the vitreous showed Nocardia nova and a diagnosis of disseminated Nocardiosis was made.

Conclusion and Significance

Although uncommon, it is important that ophthalmologists are aware of Nocardial infections as a differential diagnosis of retinal mass, particularly in immunocompromised patients.

The role of oral co-trimoxazole in treating Nocardia farcinica keratitis-a case report

BACKGROUND

Nocardia farcinica is one of the more recently identified species of the Nocardia genus. Nocardia farcinica keratitis is a rare occurrence, with only eight previously reported cases. Semi-permeable rigid contact lens use was associated with one of these reported cases. We report the first case of extended wear soft contact-lens-related Nocardia farcinica keratitis and recommend a new treatment regime.

FINDINGS

A 47-year-old lady presented with a right eye keratitis after wearing her extended wear soft contact lenses for five continuous weeks. There was no history of trauma or swimming with contact lenses in. Empirical ciprofloxacin and tobramycin eye drops were not tolerated due to ocular surface irritation on application; and instead, empirical treatment was with chloramphenicol and fortified gentamicin 1.5 % eye drops. Corneal scrapings grew Nocardia farcinica after 3 weeks-sensitive to amikacin and co-trimoxazole. Treatment was changed to amikacin 2.5 % eye drops, resulting in partial resolution of the corneal infiltrates. Oral co-trimoxazole 160/800 mg BD was added, due to cultured drug sensitivity and its high ocular penetration, with good results and a final right eye best-corrected visual acuity of 6/5.

CONCLUSION

Nocardia farcinica keratitis should be considered in the differential diagnosis of contact-lens-related keratitis. We report the first case occurring in association with extended wear soft contact lenses. Nocardia species can mimic fungal and Acanthamoeba keratitis. Treatment with oral co-trimoxazole has not been previously reported. This case demonstrates a role for co-trimoxazole in treating Nocardia farcinica keratitis based on cultured drug sensitivities.

The role of oral co-trimoxazole in treating Nocardia farcinica keratitis: a case report

Nocardia farcinica is one of the more recently identified species of the Nocardia genus. Nocardia farcinica keratitis is a rare occurrence, with only eight previously reported cases. Semi-permeable rigid contact lens use was associated with one of these reported cases. We report the first case of an extended wear soft contact lens-related Nocardia farcinica keratitis and recommend a new treatment regime. A 47-year-old lady presented with a right eye keratitis after wearing her extended wear soft contact lenses for five continuous weeks. There was no history of trauma or swimming with contact lenses in. Empirical ciprofloxacin and tobramycin eye drops were not tolerated due to ocular surface irritation on application, and instead, empirical treatment was with chloramphenicol and fortified gentamicin 1.5 % eye drops. Corneal scrapings grew Nocardia farcinica after 3 weeks-sensitive to amikacin and co-trimoxazole. Treatment was changed to amikacin 2.5 % eye drops, resulting in partial resolution of the corneal infiltrates. Oral co-trimoxazole 160 mg/800 mg BD was added, due to cultured drug sensitivity and its high ocular penetration, with good results and a final right eye best-corrected visual acuity of 6/5. Nocardia farcinica keratitis should be considered in the differential diagnosis of contact lens-related keratitis. We report the first case occurring in association with extended wear soft contact lenses. Nocardia species can mimic fungal and acanthamoeba keratitis. Treatment with oral co-trimoxazole has not been previously reported. This case demonstrates the role of co-trimoxazole in treating Nocardia farcinica keratitis based on cultured drug sensitivities.

Endogenous endophthalmitis with a visual acuity of 6/6

A 43-year-old man suffering from Klebsiella liver abscess and bacteraemia presented with left eye visual disturbance a few days after admission. His visual acuity was 6/6. There was a whitish subretinal mass located at the temporal periphery without vitritis. His visual acuity dropped to 6/120 with marked vitritis 1 day later and a diagnosis of a subretinal abscess was made. The vitreous cultures were negative. Response was suboptimal with intravitreal antibiotics, and retinotomy, vitrectomy, antibiotic irrigation and silicone oil tamponade were required. His vision gradually improved to 6/60 with silicone oil in situ. This case illustrates the rare presentation of a subretinal abscess in endogenous endophthalmitis with no initial associated vitritis, and the importance of maintaining a high level of suspicion despite good visual acuity on presentation in cases with relevant history. Early detection and intervention, and close monitoring may salvage the patient's vision in such cases.

Disseminated Nocardia farcinica: literature review and fatal outcome in an immunocompetent patient

BACKGROUND

Nocardia farcinica is a gram-positive, partially acid-fast, methenamine silver-positive aerobic actinomycete. Nocardia spp. are opportunistic pathogens, and N. farcinica is the least common species of clinical importance.

METHODS

Review of the recent literature and description of a immunocompetent patient with no known risk factors who contracted fatal N. farcinica sepsis.

RESULTS

Positive pre-mortem and post-mortem cultures from the lung and synovium correlated with acute bronchopneumonia and synovitis at autopsy. Colonies of filamentous bacteria, which were not apparent in conventional hematoxylin and eosin-stained sections, were observed with gram and methenamine silver stains, but acid-fast stains were negative. A literature review revealed that disseminated N. farcinica often is associated with an underlying malignant tumor or autoimmune disease (88% of patients). Chemotherapy or corticosteroid treatments are additional risk factors.

CONCLUSIONS

Trimethoprim-sulfamethoxazole typically is the first-line therapy for N. farcinica; treatment with amikacin and imipenem-cilastatin is used less often (7% of patients). Despite aggressive therapy, we observed that the death rate (39%) associated with N. farcinica in recent publications was eight percentage points higher than reported in a review from 2000.

Review for disease of the year: differential diagnosis of ocular toxoplasmosis

The diagnosis of ocular toxoplasmosis is mainly clinical, based in the presence of focal necrotizing retinochoroiditis often associated with a preexistent chorioretinal scar, and variable involvement of the vitreous, retinal blood vessels, optic nerve, and anterior segment of the eye. Recognition of this clinical spectrum of toxoplasmic retinochoroiditis is crucial, but other infectious, noninfectious, and neoplastic entities should also be considered in the differential diagnosis. Investigations such as serological tests, polymerase chain reaction of ocular fluids, and assessment of intraocular antibody synthesis are helpful in uncertain cases. This article provides an overview of the differential diagnosis of ocular toxoplasmosis, focusing on the most important entities to be considered and emphasizing distinctive features of each one of them in the clinical setting. Ocular toxoplasmosis has multiple clinical manifestations, which partially overlap with those of other entities and these should be carefully considered when making the differential diagnosis, particularly in less typical cases.

Nocardia farcinica Infection of a Baerveldt implant and endophthalmitis in a patient with a Boston type I keratoprosthesis

Eyes with implanted hardware carry a higher risk of infection. Here we report a rare case of Nocardia farcinica endophthalmitis and Baerveldt implant infection originating from infectious keratitis in a patient with a Boston type I keratoprosthesis. The infection resolved with aggressive surgical and medical treatment.

Nocardia farcinica lung infection in a patient with cystic fibrosis: a case report

INTRODUCTION

Respiratory tract infections are the major causes of morbidity and mortality in patients with cystic fibrosis. Nocardia are rarely implicated in these infections and few reports of the involvement of this species are found in the literature.

CASE PRESENTATION

We describe a case of lung infection followed by chronic colonization of trimethoprim and sulfamethoxazole resistant Nocardia farcinica in a patient with cystic fibrosis. The chronic colonization of this uncommon bacterium in patients with cystic fibrosis was proved using a newly developed real-time polymerase chain reaction assay, which indicates that this bacterium, despite treatment, is difficult to eradicate.

CONCLUSION

Our case report confirms that this organism can be recovered in persons with cystic fibrosis. Its eradication is necessary especially if the patient is to undergo lung transplantation.

Disseminated systemic Nocardia farcinica infection complicating alefacept and infliximab therapy in a patient with severe psoriasis

Nocardiosis is a cause of significant morbidity and mortality in the immunocompromised host, and is an infrequent complication of tumor necrosis factor alpha (TNF-alpha) blockers in chronic inflammatory diseases. Nocardiosis occurs at a rate of 3.55 and 0.88 per 100 000 patients treated with infliximab or etanercept, respectively. Disseminated nocardiosis remains an uncommon complication of these agents. Here, we present a fatal case of disseminated systemic nocardiosis in a patient with psoriasis following sequential therapy with alefacept and then infliximab therapy. The patient developed disseminated disease involving the brain, lymph nodes, and adrenal glands. The diagnosis was made by blood culture and aspiration of the adrenal gland abscess, which revealed Gram-positive bacilli and later grew Nocardia farcinica. The organism was identified by DNA sequencing, and was susceptible to moxifloxacin, gatifloxacin, ciprofloxacin, amoxicillin-clavulanic acid, linezolid, sulfamethoxazole, and amikacin. It was resistant to clarithromycin, ceftriaxone, and tobramycin and was intermediately susceptible to imipenem.