Major ReviewEndogenous Ocular Nocardiosis—An Interventional Case Report With a Review of the Literature
Introduction
About 5–10% of all endophthalmitis is endogenous. Staphylococcus sp., Streptococcus sp., Escherichia coli,53 and Candida sp.94 account for most. In a recent single-center, 10-year, retrospective study,94 Nocardia sp. represented only 3% of endogenous endophthalmitis. Nocardia was identified as the most frequent bacterial and Aspergillus as the most frequent fungal cause of a subretinal abscess.53 As the result of its slow growth and choroidal affinity, Nocardia endophthalmitis presents differently than other endogenous bacterial endophthalmitis.
Nocardia, an actinomycetale, is a fungus-like, filamentous, slow-cycling, aerobic, Gram-positive bacterium119 with variable staining. A soil saprophyte, it is found in dust and decaying vegetable matter. Immunocompromized men are particularly vulnerable to infection. The incidence of nocardiosis, defined as local or systemic infection by Nocardia, in the United States was estimated in the 1980s to be between 500 and 1,000 cases per year. Eighty-five percent (85%) of patients have a serious pulmonary or systemic infection.11 Spreading to distant sites occurs in about 20% of cases, the brain being the organ most affected (15%).11 About 3–5% of those who have bacteremia will have a focus in the eye.19 Thus, 0.6–1% of systemic nocardiosis is expected to develop endogenous ocular Nocardia (EON)—or about 3–10 cases/year in the United States. The clinical picture is highly variable. Since the introduction of sulfonamides, mortality has greatly decreased, from 80% to 25%. Visual morbidity, however, remains substantial. Lakosha et al74 found that in exo- and endogenous ocular Nocardia infections, only 13% of eyes retained visual acuities of 20/40 or more.
We report a patient who presented with a subretinal abscess as the initial manifestation of disseminated nocardiosis. Aggressive vitreoretinal surgery established diagnosis and led to a good visual outcome.
Because of the rarity of disease, the management of EON is not standardized. We analyzed all cases of EON published in Medline journals from 1967 to 2007 in form of a retrospective case series. We describe clinical presentation, methods of diagnosis, treatment efficacy, and attempt to develop criteria for the management of EON.
Section snippets
Case Report
A 78-year-old man presented with a 2-week history of painless decreased vision in his left eye. His medical history was significant for an adenocarcinoma of the prostate treated by a transurethral resection of the prostate 7 months previously and for a Hodgkin lymphoma stage IV of the sclerose-nodular type, diagnosed 2 months before presentation. At that time, he had lost 15 kg, was pancytopenic, and had hepatosplenomegaly with portal hypertension. He improved after a short course of high-dose
Inclusion criteria
Thirty-eight previously published cases with endogenous intraocular Nocardia were identified using the methods described in Section VII (Method of Literature Search). Most cases were published in English, with two in German,96, 121 and one in Portuguese.100 Thirty-seven reports presented clinical data, 17 included histological findings, and one report consisted of ocular pathology87 with little clinical data. Clinical descriptions were all detailed except one, which was a description of a brain
Systemic features and mortality of nocardiosis in patients with EON
Thirty-seven clinical and one pathologic87 case were identified and analyzed. Overall, 47 eyes were affected by endogenous intraocular nocardiosis. Table 1 gives an overview of patients’ age, sex, Nocardia species, underlying disease, steroids, immunosuppressives, and outcome.
Comparison of ophthalmic reports with nocardiosis in general
The cases published in the ophthalmic literature are similar (age distribution, strong male predominance, underlying diseases, corticosteroids as major risk factor, clinical picture of fever, weight loss, skin lesions, and mortality) to those from the non-ophthalmic literature.11, 81, 119 Underrepresented in the ophthalmic literature are patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (see subsequent discussion) and patients with chronic pulmonary
Conclusion
Half of the patients presented first with ocular symptoms. Insidious painless loss of vision caused by chorioretinal infiltrates or a mass lesion with overlying hemorrhages in the macular region with a relative mild inflammatory reaction is typical for EON. Nocardia either progresses inwards with vitreal sequestration or outwards causing perforation. Signs of severity that exteriorization is imminent are severe ocular pain with either proptosis or a hypopyon—or with both.
A biopsy for adequate
Method of Literature Search
A literature search of case reports of endogenous ocular Nocardia was conducted using OVID Medline (1950–2007), EMBASE by meshing keywords Nocardia/nocardiosis and eye, ocular, endogenous, endophthalmitis, subretinal abscess, uveitis. Additional manual searches were conducted by using Index Medicus (1888–1917), Quarterly Cumulative Index Medicus (1917–1950), Excerpta Medica (1947–1966), Ophthalmic Literature (1947–1966), Zentralblatt für die Gesamte Ophthalmologie und ihre Grenzgebiete
Disclosure
The authors reported no proprietary or commerical interest in any product mentioned or concept discussed in this article. This article was supported by Schweizerischer Fonds zur Verhütung und Bekämpfung der Blindheit, Zürich and the Swiss National Science Foundation (MEEM).
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Cited by (0)
The authors offer their thanks to the colleagues at the CHUV who managed the patient and to their colleagues at the Jules Gonin Eye Clinic: to Sylvie Uffer for the Gram staining and pictures in Figure 2, to Marc Curchot for the pictures, to Madelaine Badan for bibliography support, and to Alexander Moulin for the autopsy. Furthermore, they wish to thank Mahnaz Nouri (Boston, MA) for corrections, Peter Keller from the microbiology laboratory university hospital, Zürich for discussion and corrections, and Martin Eschle for IT support.