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

Subretinal abscess: causative pathogens, clinical features and management

Purpose

To review the literature on endogenous subretinal abscess (SRA).

Methods

We searched in the literature for the terms ‘subretinal abscess’, ‘chorio-retinal abscess’ and ‘choroidal abscess’.

Results

A total of 122 patients were identified, of whom 20 patients (22 eyes) had no identified systemic infective foci (group 1) and 102 (120 eyes) had systemic infective foci (group 2). The mean age for group 1 was 44.6 years (range 2 weeks-82 years) and for group 2 was 43.2 years (range 1–89 years). The responsible pathogen was identified in 90% and 95% of cases, respectively. In group 1 the most frequent causative agents were Aspergillus and Nocardia, while in group 2 were Nocardia, Mycobacterium Tuberculosis and Klebsiella. In both groups the most common symptoms were reduced vision (70% and 72.5%, respectively), pain (65% and 29.4%, respectively) and redness (35% and 17.6%, respectively). For group 1 there was no difference between mean initial and final visual acuity (1.7 logMAR, range 0–3 logMAR), while for group 2 mean initial and final visual acuities were 0.8 logMAR and 0.6 logMAR, respectively. Final visual acuity was significantly better in group 2 (p = 0.003). Anterior segment inflammation was seen in 77.3% of cases of group 1 and 66.7% of cases of group 2. In both groups the abscess most common locations were posterior pole (45.4% and 32.5%, respectively) and temporal periphery (13.6% and 13.3%, respectively). Clinical features included hemorrhages (76.5% and 76.3%, respectively) and subretinal fluid (75% in both groups). Diabetes mellitus (20% and 25.5%) and immunosuppressive drug intake (35% and 23.5%) were the main predisposing factors for SRA. Combination of systemic and intravitreal antibiotics/antifungals and vitrectomy was the main therapeutic strategy for both groups. Systemic treatment alone was used mainly for cases of tubercular etiology. The timing of vitrectomy differed between the two groups, as it more commonly followed the use of systemic and intravitreal antibiotics in the forms associated with systemic infective foci. Additional abscess drainage or intralesional antibiotics were performed in 23.8% of cases.

Conclusion

At present no guideline exists for the treatment of subretinal abscess. Systemic broad-spectrum antibiotic treatment is of primary importance and should be used in all cases unless contraindicated. Combination of systemic and local treatment is the most frequently adopted strategy.

Resolution of Isolated Subretinal Abscess with Systemic Antibiotic Treatment

PURPOSE

To describe clinical features and therapeutic management of a case of isolated subretinal abscess (SRA) in an immunocompetent male patient with no predisposing conditions or risk factors.

METHODS

Clinical data, including medical history, clinical findings and results of systemic investigations, were retrospectively collected in a 40-year-old man diagnosed with unilateral focal SRA.

RESULTS

Systemic investigations did not reveal any extraocular infective focus. Prompt diagnosis of SRA and aggressive systemic antibiotic treatment averted breakthrough into the vitreous cavity and led to clinical resolution with preservation of visual acuity. No local recurrences or distal spread of the infection were found at follow-up.

CONCLUSIONS

In isolated SRA, timely systemic antibiotic treatment can lead to an excellent clinical outcome. Close monitoring is essential to prevent potential progression of SRA to a sight-threatening endophthalmitis, which would prompt an urgent shift in the therapeutic approach.

PSEUDOMONAL CHOROIDAL ABSCESS AFTER ROUTINE PARS PLANA VITRECTOMY IN AN IMMUNOSUPPRESSED PATIENT

PURPOSE

To describe an unusual case of pseudomonal choroidal abscess which developed after a routine pars plana vitrectomy in an immunosuppressed patient.

METHODS

Case report. A 61-year-old woman with a history of rheumatoid arthritis and ulcerative colitis on abatacept underwent pars plana vitrectomy. A few days after the patient's operation, a partially serous choroidal detachment was identified. Her choroidal detachment increased in size despite prednisone therapy, and she was taken to the operating room for repeat vitrectomy and choroidal drainage. Intraoperatively, there was no significant intraocular inflammation, but purulent whitish material was expressed during external choroidal drainage which grew Pseudomonas aeruginosa.

RESULTS

The patient was given intravenous antibiotics. Systemic infectious workup was negative for blood and urine cultures. The patient was transitioned to oral antibiotics, but had persistent eye pain after discharge and vision remained at count fingers. A computed tomography orbit scan with contrast showed persistent choroidal abscess, and intravitreal ceftazidime injections were administered. The patient's subjective pain resolved within several days of the first intravitreal injection; repeat ultrasound also showed interval resolution of the choroidal elevation. One year after the resolution of her choroidal abscess, her visual acuity was Snellen 20/250 in the affected eye.

CONCLUSION

Isolated choroidal bacterial abscess is a possible, but rare, complication of pars plana vitrectomy. Although visual prognosis is poor, especially for pseudomonal choroidal abscesses, aggressive treatment with timely choroidal drainage, systemic antibiotics, and intravitreal antibiotics may allow recovery of some ambulatory vision.

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.

Antimicrobial guide to posterior segment infections

PURPOSE

This review article is meant to serve as a reference guide and to assist the treating physician in making an appropriate selection and duration of an antimicrobial agent.

METHODS

Literature review.

RESULTS

Infections of the posterior segment require prompt medical or surgical therapy to reduce the risk of permanent vision loss. While numerous options exist to treat these infections, doses and alternative therapies, especially with contraindications for first-line therapy, are often elusive. Antimicrobial agents to treat posterior segment infections can be administered via various routes, including topical, intravitreal, intravenous, and oral.

CONCLUSIONS

Although there are many excellent review articles on the management of endophthalmitis, we take the opportunity in this review to comprehensively summarize the appropriate antimicrobial regimen of both common and rare infectious etiologies of the posterior segment, using evidence from clinical trials and large case series.

Nocardia endophthalmitis in a child: Distinct clinical and imaging features on orbital CT scan

Nocardia is a rare cause of endophthalmitis in immunocompetent individuals with poor visual outcomes. We, herein report a 15 month otherwise healthy child, who presented with hyphema, vitreous hemorrhage and secondary glaucoma following a vague history of trauma in the left eye 2 months before presentation. He presented a week later with features of panophthalmitis which were confirmed on B-scan and orbital CT scan. CT scan with contrast revealed the presence of multiple ring enhancing abscesses in the vitreous cavity and also in the intraconal space. Evisceration was done and smear and cultures revealed Nocardia. Rare presentation in a healthy pediatric patient and typical CT scan findings are discussed.

Resolution of subretinal abscess from presumed Nocardia chorioretinitis with serial intravitreal amikacin

Nocardia subretinal abscess is a rare complication of nocardiosis with typically poor visual outcomes. We present a case of a large submacular abscess that responded favorably to early, frequent intravitreal amikacin along with systemic antibiotic therapy.

ENDOGENOUS NOCARDIA ENDOPHTHALMITIS PRESENTING AS A MASS LESION IN A PATIENT WITH METATSTATIC NONSMALL CELL CARCINOMA OF THE LUNG

PURPOSE

To report a case of Nocardia cyriacigeorgica endophthalmitis.

METHODS

Case report.

RESULTS

A 71-year-old man on long-term steroid therapy for poor respiratory function from lung carcinoma and presumed recent liver metastases presented with a four week history of blurry vision in the left eye. Ophthalmic examination revealed a white elevated mass in the macula with hemorrhage, concerning for metastasis. The patient was treated for presumed ocular metastases but had poor response to radiotherapy and was diagnosed four weeks later with N. cyriacigeorgica by retinal biopsy. Despite intravitreal and systemic antibiotics, the patient had progression of disease and died of respiratory involvement.

CONCLUSION

Nocardia endogenous endophthalmitis can present as a mass retinal lesion in immunosuppressed patients with metastatic disease. Early vitreous and retinal biopsy may be required for definitive diagnosis and treatment. A pulmonary source of infection should be suspected and monitored closely.

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.