Endogenous Nocardia asteroides subretinal abscess diagnosed by transvitreal fine-needle aspiration biopsy

Endogenous ocular nocardiosis

Nocardiosis is an extremely rare, opportunistic, Gram-positive bacterial infection that has a high mortality rate in those patients who are immunocompromised in the presence of disseminated disease.

We describe a case of an elderly lady being treated with high-dose corticosteroids for giant cell arteritis that presented with ischaemic optic atrophy. Subsequent deterioration was accompanied by the development of subretinal lesions. Further extensive evaluation discovered she had pulmonary nocardiosis with widespread dissemination. The case has several learning points, in particular:

Subretinal abscesses maybe a harbinger of serious hitherto undiagnosed infection which portend a poor prognosis.

Vital signs in the immunocompromised may appear to be normal in the presence of serious infection.

Nocardia Subretinal Abscess: A Rare and Challenging Case Report

Purpose

To describe a positive clinical response of a patient with submacular Nocardia abscess due to a rapid and efficient treatment. Case report. We describe a case of a 50-year-old man with a painless visual decline of the left eye. Four years later, he had been diagnosed with systemic nocardiosis. Examination of the left eye revealed a submacular white mass with fluffy borders and another smaller white lesion, with well-defined borders, in the inferior temporal vascular arch. A systemic antibiotic treatment with SMX-TMP and intravenous imipenem and a single intravitreal injection of bevacizumab was performed.

Conclusion

Prompt diagnosis and treatment ensured an expeditious resolution of the abscess and significant improvement of visual acuity. The diagnostic approach of a high index of suspicion coupled with directed treatment is required when dealing with subretinal inflammatory lesions.

Ocular Nocardiosis: A Case Report

Purpose: To describe the challenging diagnosis of ocular nocardiosis in a patient with anaplastic astrocytoma Methods: A 56-year-old patient with recurrent cerebral anaplastic astrocytoma and a history of surgical resection, who underwent radiotherapy and chemotherapy, presented with a unilateral white subretinal mass at the posterior pole of his left eye. Vitrectomy and fine-needle biopsy of the vitreous as well as the subretinal mass were performed. Results: Magnetic resonance imaging verified progression of the lesion's size at follow-up. Histopathological workup of the material revealed gram-positive filamentous bacteria consistent with Nocardia cyriacigeorgica. Conclusion: Endogenous Nocardia should be suspected in case of choroidal abscess in immunocompromised patients. Clinical diagnosis is challenging; therefore, early subretinal biopsy should be considered to facilitate treatment decision.

Endogenous endophthalmitis due to Roseomonas mucosa presenting as a subretinal abscess

Background

Endogenous bacterial endophthalmitis is an infrequently reported entity. Although Roseomonas mucosa has been reported to cause systemic infections in immunosuppressed individuals, ocular infection due to Roseomonas has been rarely reported in literature previously.

Findings

A 74-year-old diabetic was diagnosed to have Klebsiella urinary tract infection and septicemia following which he developed ocular pain and redness. Further investigation revealed endophthalmitis with subretinal abscess and retinal detachment. The patient underwent pars plana vitrectomy with drainage of the abscess and silicone oil tamponade. The subretinal aspirate was found to contain R. mucosa confirmed on culture and PCR.

Conclusion

Microbiological evaluation of the subretinal purulent material revealed pink-colored colonies. Nested PCR was positive for detection of the eubacterial genome as well as for detection of the Mycobacterium tuberculosis genome (Ref)-targeting MPB64 gene. PCR examination of the subretinal pus sample ruled out M. tuberculosis and confirmed R. mucosa. The occurrence of Roseomonas endogenous endophthalmitis presenting as a subretinal abscess has not yet been reported in English literature so far to the best of our knowledge.

Intralesional antibiotic injection using 41G needle for the management of subretinal abscess in endogenous endophthalmitis

BACKGROUND

Presence of subretinal abscess in endogenous endophthalmitis indicates a more severe form of infection. Available reports indicate variable response to standard treatment with systemic, intravitreal pharmacotherapy and vitreous surgery. There are no reports citing the possible role of intralesional antibiotic therapy in managing subretinal abscess.

CASE PRESENTATION

A 30 year old lady presented with features of endogenous endophthalmitis and subretinal abscess. Presenting vision was finger counting close to face. Despite prompt initiation of systemic antibiotics and intravitreal injection, no response was noted. 25G pars plana vitrectomy was performed along with injection of vancomycin directly into the subretinal abscess, using a 41G needle. Postoperative course was uneventful and the abscess showed signs of rapid resolution. Visual acuity improved to 6/24.

CONCLUSION

Intralesional pharmacotherapy may be safe and effective in the treatment of subretinal abscess associated with endogenous endophthalmitis.

Clinical Profile of Patients with Tubercular Subretinal Abscess in a Tertiary Eye Care Center in Southern India

PURPOSE

To retrospectively analyze clinical features, laboratory investigations, treatment and visual outcomes in patients with tubercular subretinal abscess.

METHODS

A total of 12 eyes of 12 patients receiving a diagnosis of subretinal abscess, between 2004 and 2014, were included for this retrospective study.

RESULTS

The mean age of the presentation was 29.75 ± 16.72 years (range: 14-62 years) and seven (58.3%) were male. The most common anterior segment presentation was anterior uveitis (75%). The mean BCVA at presentation was 1.62 (in logMAR). A tuberculin skin test was positive in seven patients (58.3%) and five patients had a history of pulmonary tuberculosis. Polymerase chain reaction for the Mycobacterium tuberculosis genome was positive in 6 of 11 eyes from aqueous aspirate (54%) and 4 of 7 eyes from vitreous aspirates (57.14%). All patients were started on systemic steroids and an anti-tubercular regimen. The mean duration of follow-up was 134.28 days. The mean BCVA at final presentation was 1.19 (in logMAR). Chorioretinal scar was the most common finding after resolution.

CONCLUSIONS

Subretinal abscess is a rare manifestation of ocular tuberculosis. A high degree of suspicion and timely management of the condition can prevent loss of vision.

NOCARDIA CHOROIDAL ABSCESS: Risk Factors, Treatment Strategies, and Visual Outcomes

PURPOSE

To describe the risk factors, clinical course, ancillary test findings, treatment strategies, and visual outcomes of a series of patients with choroidal abscesses caused by endogenous Nocardia.

METHODS

This retrospective, consecutive noncomparative case series included all patients with Nocardia ocular infections at 3 tertiary medical centers over the past 20 years.

RESULTS

Five eyes in 5 patients were identified with choroidal abscesses because of Nocardia. All patients were immunocompromised: one suffered from AIDS and four had autoimmune disorders. Three of the 5 patients (60%) underwent systemic evaluation, and in all 3, nonocular nocardiosis was identified. Four patients (80%) underwent diagnostic ophthalmic surgery and received systemic and intravitreal antibiotics. The final patient deferred these interventions. Outcomes at the last follow-up examination were 20/25, 1/200, hand motion at 1 foot, and 2 patients underwent enucleation. Mean follow-up (± standard deviation) was 159 (± 103) days.

CONCLUSION

Immunosuppression is the most significant risk factor for developing Nocardia choroidal abscesses. Definitive diagnosis generally requires subretinal biopsy, which is also critical to implementing appropriate antibiotic therapy.

Metastatic endophthalmitis combined with subretinal abscess in a patient with diabetes mellitus--a case report

Background

Endogenous endophthalmitis, extra-hepatic metastasis from liver abscess with diabetes mellitus, could lead to a devastating outcome without a prompt and appropriate management. We report a case of metastatic endophthalmitis combined with subretinal abscess with successful visual outcome after treatment.

Case presentation

A 56-year-old male patient with diabetes mellitus under poor control presented to our emergency room with fever, sore throat, cough and poor appetite for 2 weeks. Abdominal computed tomography showed a 2.2 × 2.0 cm liver abscess. During hospitalization, sudden onset of blurred vision with floaters in his left eye was noted.

Meanwhile, Brain computed tomography demonstrated subdural abscess in right parietal area. With obvious vitritis, a localized subretinal abscess was also found over temporal arcade with size about four disc areas under indirect ophthalmoscopy. A pars plana vitrectomy with intravitreal injection of ceftazidime (2 mg/0.1 ml) and amikacin (0.4 mg/0.1 ml) was performed without retinectomy. The margin of the subretinal abscess became firm and the central area resolved after the operation. Finally, his vision improved to 6/6 after cataract surgery.

Conclusions

Subretinal abscess is an extremely rare presentation of metastatic endophthalmitis. It is difficult to develop appropriate treatment guidelines of endophthalmitis complicated with subretinal abscess. Our experience in this case demonstrated if the size of the subretinal abscess is smaller than four disc areas, pars plana vitrectomy with intravitreal injection of antibiotics without retinectomy could be considered to avoid further retinal detachment.

Nocardia asteroides subretinal abscess in patient with acute myelogenous leukemia after allogeneic stem cell transplant

PURPOSE

Nocardia asteroides is the most common bacterial cause of subretinal abscesses; however, the diagnosis is often delayed because of the lack of suspicion leading to poor visual prognosis and possible enucleation.

METHODS

A 40-year-old man with a history of allogeneic stem cell transplant presents with decreased vision and a macular subretinal abscess.

RESULTS

Examination revealed decreased vision at 20/100 with a peripapillary creamy subretinal lesion extending to the nasal margin of the fovea associated with intraretinal and subretinal hemorrhages without vitritis. Workup revealed disseminated N. asteroides, confirmed with a skin biopsy with the involvement of skin, eyes, lungs, and brain. Intravitreal amikacin and vancomycin were promptly given along with systemic vancomycin, sulfamethoxazole/trimethoprim, and meropenem. Vision improved rapidly to 20/40 with stabilization and eventual scarring of the lesion.

CONCLUSION

This case illustrates that rapid diagnosis and treatment of subretinal N. asteroides can possibly have a good visual outcome and stabilization of the ocular manifestations.

Biopsy pathology in uveitis

Uveitis is fraught with speculations and suppositions with regard to its etiology, progress and prognosis. In several clinical scenarios what may be perceived as due to a systemic infection may actually not be so and the underlying etiology may be an autoimmune process. Investigations in uveitis are sometimes the key in identification and management. Invasive techniques could be of immense value in narrowing down the etiology and help in identifying the cause. This article updates one on the invasive techniques used in biopsy such as anterior chamber paracentesis, vitreous tap and diagnostic vitrectomy, iris and ciliary body biopsy, choroidal and retinochoroidal biopsy and fine needle aspiration biopsy (FNAB). In populations where certain infections are endemic, the clinical scenario does not always respect a known presentation and the use of biopsy is resorted to as a sure way of confirming the etiology. Biopsies have a role in diagnosis of several inflammatory and infectious conditions in the eye and are pivotal in diagnosis in several dilemmas such as intraocular tumors and in inflammations. Appropriate and timely use of biopsy in uveitis could enhance the diagnosis and provide insight into the etiology, thus enabling precise management.

[Endogenous bacterial endophthalmitis]

Endogenous bacterial endophthalmitis, also called metastatic bacterial endophthalmitis, remains a diagnostic and therapeutic challenge. It is a rare and potentially sight-threatening ocular infection that occurs when bacteria reach the eye via the bloodstream, cross the blood-ocular barrier, and multiply within the eye. It usually affects immunocompromised patients and those suffering from diabetes mellitus, malignancy, or cardiac disease, but has also been reported after invasive procedures or in previously healthy people. In most cases, the ocular symptoms occur after the diagnosis of septicemia or systemic infection. Ocular symptoms include decreased vision, redness, discharge, pain, and floaters. The ocular inflammatory signs may be anterior and/or posterior. Bilateral involvement occurs in nearly 25% of cases. A wide range of microorganisms are involved, with differences in their frequency according to geography as well as the patient's age and past medical history, because of variations in the predisposing conditions and the source of the sepsis. The majority of patients are initially misdiagnosed, and ophthalmologists should be aware of this because prompt local and general management is required to save the eye and/or the patient's life.

Two cases of nocardiosis diagnosed by fine-needle aspiration cytology: role of special stains

Nocardiosis, a suppurative disease caused by aerobic actinomycetes, is a common opportunistic infection in immunocompromised patients. Unless, the infection is suspected, the diagnosis of Nocardia is tedious and difficult, as these are thin filamentous bacilli, which stain negatively on routine cytological stains. We present two such cases diagnosed on fine-needle aspiration cytology and discuss the importance of performing the modified Ziehl-Neelsen stain in such cases.

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

PURPOSE

To report a case of subretinal abscess due to Nocardia farcinica resistant to trimethoprim-sulfamethoxazole in a patient with systemic lupus erythematosus on immunosuppressive therapy.

DESIGN

Observational case report.

METHODS

We retrospectively studied the medical record of a patient with nocardiosis.

RESULTS

The microorganism disseminated from the lungs (pneumonia) to the eye and brain. The ocular lesion appeared to be a yellowish, lobulated subretinal abscess with irregular surface and superficial retinal hemorrhages. As it was not responding to empiric therapy for nocardia, pars plana vitrectomy and aspiration of the subretinal material was performed to confirm the etiology.

CONCLUSION

In an immunocompromised patient with pulmonary involvement and a subretinal abscess with a characteristic aspect, one should consider nocardia as a possible etiology taking into account its possible antibiotic resistances.

Histology of retina overlying bacterial subretinal abscess and implications for treatment

PURPOSE

To evaluate the state of the retina overlying a subretinal abscess and its contents by histopathologic analysis and electron microscopy (EM) and to determine implications for treatment.

METHODS

Case report of a patient with a subretinal abscess secondary to Klebsiella pneumoniae infection who underwent pars plana vitrectomy, PPL, endolaser, retinectomy, abscess drainage, and retinal biopsy. The retinal biopsy was analyzed histologically using special stains, and EM of the abscess contents was performed.

RESULTS

Postoperatively, the retina remained attached, and the patient regained visual acuity of 20/60. Culture of the vitrectomy specimen yielded K. pneumoniae. Retinal biopsy revealed a partially intact inner retina with destruction of the outer retinal layers in the setting of acute inflammation. Results of gram, Grocott-Gomori methenamine-silver nitrate, and acid-fast staining of the retinal biopsy specimen were negative. EM of the abscess contents revealed cellular debris with scattered inflammatory cells but no bacteria.

CONCLUSION

This case demonstrates that aggressive surgical management of a subretinal abscess due to K. pneumoniae in an eye can result in useful vision. Management included retinectomy of the retina overlying the abscess that revealed photoreceptor destruction with intraretinal inflammation. Drainage of a subretinal abscess without removal of the overlying retina may limit treatment effectiveness and spare retina that is not functional.

Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases

Endogenous bacterial endophthalmitis is a rare but serious condition that occurs when bacteria cross the blood-ocular barrier and multiply within the eye. We provide an overview of endogenous bacterial endophthalmitis by reviewing 267 reported cases and integrating this with our experience of an additional 19 cases. The majority of patients with endogenous bacterial endophthalmitis are initially misdiagnosed and many have an underlying disease known to predispose to infection. This condition is often previously undiagnosed. Blood cultures are the most frequent means of establishing the diagnosis. The most common Gram positive organisms are Staphylococcus aureus, group B streptococci, Streptococcus pneumoniae,and Listeria monocytogenes. The most common Gram negative organisms are Klebsiella spp., Escherichia coli, Pseudomonas aeruginosa, and Neisseria meningitidis. Gram negative organisms are responsible for the majority of cases reported from East Asian hospitals, but Gram positive organisms are more common in North America and Europe. The visual outcome is poor with most cases leading to blindness in the affected eye. Many patients have extraocular foci of infection, with an associated mortality rate of 5%. The outcome of endogenous bacterial endophthalmitis has not improved in 55 years and clinicians need to have a high level of awareness of this commonly misdiagnosed condition.

Bacterial subretinal abscess: a case report and review of the literature

PURPOSE

To report a case of Klebsiella subretinal abscess with a successful visual outcome with treatment and to review the literature pertaining to focal intraocular infection in bacterial endophthalmitis.

METHODS

Clinical data including medical history, findings on physical examination, blood cultures, and an abdominal computed tomographic scan were collected in a 32-year-old man with Klebsiella sepsis, liver abscesses, and a focal subretinal abscess. Ocular data including visual acuity, fundus photographs, fluorescein angiography, and ultrasound were evaluated, as were results of culture and histopathologic studies.

RESULTS

Despite immediate intervention, including vitreous tap and intravitreal antibiotics, the eye deteriorated, with enlargement of the abscess. A pars plana vitrectomy was performed in which the subretinal abscess material was removed after an extensive retinectomy of the involved area in association with an endophotocoagulative barrier and intravitreal amikacin without gas or oil tamponade. Culture confirmed Klebsiella subretinal infection. A retinal detachment occurred 1 month postoperatively and was successfully repaired. Visual acuity was 20/30 and has remained stable for 14 months.

CONCLUSION

Klebsiella endophthalmitis with subretinal abscess formation is a rare but devastating ocular condition. In the present case, prompt intervention with extensive retinectomy, complete abscess excision, and intravitreal antibiotic therapy resulted in unprecedented visual recovery.

Nocardia choroidal abscess in a patient with systemic lupus erythematosus

PURPOSE

Nocardia asteroides, a respiratory saprophyte in humans, may cause localized infection of the lungs in debilitated or immunosuppressed individuals. Haematogenous spread to the eye via the choroidal circulation may result in choroidal abscess formation.

METHOD

We report the development of a choroidal abscess in the left eye of a woman treated with steroids and cyclophosphamide for systemic lupus erythematosus. Haematogenous spread of N. asteroides from a localized infection of the lung (empyema) is thought to have been the cause of the choroidal abscess.

RESULTS

Surgical drainage of the empyema combined with intravenously administered antibiotics resulted in resolution of the choroidal abscess and improvement of vision.

CONCLUSIONS

A choroidal abscess, caused by haematogenous spread of N. asteroides, may respond to appropriate systemic antibiotic treatment alone and not require ocular treatment.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

The medically important aerobic actinomycetes: epidemiology and microbiology

The aerobic actinomycetes are soil-inhabiting microorganisms that occur worldwide. In 1888, Nocard first recognized the pathogenic potential of this group of microorganisms. Since then, several aerobic actinomycetes have been a major source of interest for the commercial drug industry and have proved to be extremely useful microorganisms for producing novel antimicrobial agents. They have also been well known as potential veterinary pathogens affecting many different animal species. The medically important aerobic actinomycetes may cause significant morbidity and mortality, in particular in highly susceptible severely immunocompromised patients, including transplant recipients and patients infected with human immunodeficiency virus. However, the diagnosis of these infections may be difficult, and effective antimicrobial therapy may be complicated by antimicrobial resistance. The taxonomy of these microorganisms has been problematic. In recent revisions of their classification, new pathogenic species have been recognized. The development of additional and more reliable diagnostic tests and of a standardized method for antimicrobial susceptibility testing and the application of molecular techniques for the diagnosis and subtyping of these microorganisms are needed to better diagnose and treat infected patients and to identify effective control measures for these unusual pathogens. We review the epidemiology and microbiology of the major medically important aerobic actinomycetes.

Nocardia choroidal abscess

Nocardia is a Gram positive, aerobic, filamentous branching micro-organism that rarely causes human infection. When infection does occur it usually takes the form of a subcutaneous abscess or a pneumonia-like illness. We describe a case of a patient with chronic lymphocytic leukaemia who developed painless loss of vision in the right eye secondary to a choroidal abscess after a prolonged course of treatment on several immunosuppressive agents. The patient also complained of right shoulder pain that was unresponsive to conventional therapy, and had been admitted and treated for several episodes of 'pneumonia'. A diagnostic transvitreal fine-needle aspiration biopsy of the ocular lesion was performed which demonstrated Nocardia asteroides. This allowed for appropriate antibiotic therapy to be instituted early in the course of the infection and prompted the systemic work-up which also demonstrated central nervous system and arthropic nocardial infection.