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Intraocular Nocardiosis
INTRAOCULAR
NOCARDIOSIS
L E E M . J A M P O L , M.D., BARRY S. S T R A U C H , M.D., A N D D A N I E L M . A L B E R T , M . D .
New Haven, Connecticut With the increasing use of immunosuppressive agents in patients receiving organ transplants and intensive chemotherapy in patients with neoplastic disease, infections with opportunistic organisms are becoming disturbingly common.1-7 In debilitated pa tients in general, infections with opportunis tic fungi (e.g., Candida, Aspergillus), vi ruses (e.g., cytomegalovirus), and other or ganisms (e.g., Pneumocystis carinii) are be ing frequently reported. Nocardia astér oïdes has also become a significant pathogen in many of these patients, and the eye find ings may be a valuable clue in diagnosing nocardial infection. We describe a renal trans plant patient who developed systemic nocardiosis, and in whom chorioretinal abscesses were a striking clinical finding. Despite vig orous antibiotic therapy the patient died. Postmortem examination allowed histopathologic evaluation of the eye changes and cor relation with the clinical findings. CASE REPORT
A 40-year-old white man was in good health un til 1967 when he had the onset of fatigue and arthralgias. A pulmonary nodule, proteinuria, and hematuria were present. A renal biopsy was inter preted as being consistent with Wegener's granulomatosis. Eye evaluation at that time revealed bilat eral episcleritis that subsequently improved with topical corticosteroid administration. Other findings on the eye examination were within normal limits. The patient received systemic corticosteroids and azathioprine and showed initial improvement. By 1969, however, progressively deteriorating renal function necessitated chronic hemodialysis. In No vember 1971, he received a cadaveric renal trans plant, and after an initial period of acute tubular From the Department of Ophthalmology and Visual Science, and the Department of Medicine, Yale University School of Medicine, New Haven, Connecticut. This study was supported in part by Public Health Service Grant EY-00002, Research to Prevent Blindness, Inc., and the Connecticut Lions Eye Research Foundation, Inc. Reprints requests to Lee M. Jampol, M.D., Yale University School of . Medicine, Department of Ophthalmology, New Haven, CT 06510.
necrosis, his renal function improved. Immunosuppressive therapy to prevent rejection of the trans plant included azathioprine, 2 to 3 mg/kg, and high doses of prednisone. Therapy was continued, and the transplanted kid ney functioned well until February 1972, when he was admitted to Yale-New Haven Hospital with chills and fever, There were tender erythematous abscesses on the left forearm and two areas on his back. Nocardia astéroïdes was seen on smear from these lesions and grew out in culture. Treatment with sulfadiazine, 8 g/day, was started, and after one week, sulfisoxazole, 8 g/day, was added. One week later the sulfadiazine was stopped, and sulfi soxazole, 16 g/day, was continued for five addi tional weeks. At this point a generalized rash devel oped which resolved with discontinuation of the sul fisoxazole. The skin abscesses healed well, and there was no evidence of dissemination of the infection. On May 3, 1972, the patient was readmitted because of deterioration of his renal function. A renal biopsy showed acute rejection. Treatment with high doses of prednisone was reinstituted. Two weeks later he began having daily febrile spikes, and one week following this, complained of blurring of vi sion. Eye evaluation on May 24, showed the visual acuity to be 20/60 in the right eye and 20/25 in the left eye. Findings on external and slit-lamp exami nations were within normal limits as were the intra ocular pressures. Examination of the right fundus demonstrated four elevated white-yellow choroidal infiltrates with overlying retinal detachment and retinal hemorrhages (Fig. 1). The appearance of the left fundus was normal. A repeat chest x-ray (Fig. 2) showed multiple nodules in both lungs, and an open lung biopsy revealed miliary abscesses. Cul tures grew out N. astéroïdes. Despite therapy with sulfisoxazole, ampicillin, and streptomycin, the patient's condition deterio rated, and he became comatose. We examined the fundi daily, and the choroidal lesions remained es sentially unchanged until the patient's death on June 11. General pathologic findings—Autopsy revealed bi lateral scarred kidneys and evidence of mild rejec tion in the transplanted kidney. The transplant showed perirenal inflammatory changes, but no or ganisms were isolated from the transplant. In addi tion, the liver and lungs contained cerebral microabscesses and old healed granulomas, which were ster ile on smear and culture. Nocardia astéroïdes was identified only in the prostate and the right eye. Pathologic findings in the eye—Both eyes were sub mitted to the Yale Eye Pathology Laboratory. Upon sectioning the right eye, we saw four distinct
568
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INTRAOCULAR NOCARDIOSIS
Fig. 1 (Jampol, Strauch, and Albert). Fundus photograph demonstrating chorioretinal abscess ad jacent to the disk. The retina overlying the lesion is elevated with areas of retinal hemorrhage. chorioretinal infiltrates in the posterior pole (Fig. 3). Microscopic sections of the right eye revealed an unremarkable cornea, anterior chamber, lens, iris, and ciliary body. The vitreous cavity was clear. The choroid demonstrated areas of marked thickening with infiltration by large numbers of lymphocytes and plasma cells, and occasional polymorphonuclear leukocytes (Figs. 4 and 5). Some choroidal hemor rhage was seen. Overlying the choroidal abscesses, Bruch's membrane was largely intact but with dis rupted pigment epithelium (Fig. 5). The retina overlying the abscesses was detached and showed
Fig. 3 (Jampol, Strauch, and Albert). Appear ance of two of chorioretinal abscesses (arrows). The lower abscess corresponds to the lesion seen in Figure 1. foci of retinal necrosis with disorganization and de generation. In areas, beneath the detached neural retina, and also beneath the pigment epithelium, were chronic inflammatory cells and cellular debris. Brown-Brenn stains demonstrated a filamentous or ganism proliferating along Bruch's membrane with extension into the subretinal space (Fig. 6). Histologically the organism was consistent with N. astér oïdes. Occasional organisms were seen in the cho roid itself. The optic nervehead was edematous with involvement of the surrounding nerve fiber layer. The choroid and retina in areas not involved by the Nocardia organisms were completely normal. The sciera was unremarkable. The left eye was normal grossly and microscopically. The diagnosis was (1) N. astéroïdes choroidal abscesses of the right eye, and (2) exudative de tachment of the overlying retina with retinal necro sis. DISCUSSION
Fig. 2 (Jampol, Strauch, and Albert). Chest x-ray showing bilateral nocardial pneumonitis.
Nocardia astéroïdes is a filamentous Gram-positive organism that was originally classified as a fungus. Recently Nocardia, as well as its relative Actinomyces, have been recognized to be more closely related to the bacteria. Although Nocardia organisms can easily be isolated from soil, they were rarely noted to be pathogenic until recent years. In fection by this organism is usually seen in debilitated patients, especially those with
570
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER, 1973
Fig. 4 ( Jampol, Strauch, and Albert). Low-power view of a nocardial lesion. Note the choroidal and ret inal portions of the abscess. Arrow indicates Bruch's membrane. In this section, the retina is largely replaced by inflammatory cells and cellular debris (hematoxylin-eosin, XlOO).
Fig. S (Jampol, Strauch, and Albert). Higher power view of the abscess. The retina in this section is largely intact, although it is detached. The pigment epithelium is disrupted centrally. R indicates retina; S, subretinal debris; P, pigment epithelium; B, Bruch's membrane; and C, choroid (hematoxylin-eosin, X400).
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Fig. 6 (Jampol, Strauch, and Albert). Proliferation of Nocardia along retinal side of Bruch's membrane (Brown-Brenn, X 1,000).
cancer, dysproteinemias, disseminated lupus, and other conditions associated with im paired immunologie mechanisms.7 Patients on systemic corticosteroids and other immunosuppressives, particularly renal transplant patients, have a significant incidence of no cardial infection.1"4 The clinical manifestations of nocardial infection frequently include bronchopneumonia or lobar pneumonia, and disseminated abscesses often appear, particularly in the skin, brain, liver, and scrotum. Although it is uncertain whether Nocardia can be a con taminant, when the organism is isolated it is usually considered pathogenic. Unfortu nately cultures and Gram stains can initially be negative despite active nocardial disease. When the organism is the cause of infection, patients often respond well to sulfonamide therapy. Although Nocardia shows a sensi tivity in vitro to other antibiotics, clinically these have proved disappointing. Keratitis, 8 conjunctivitis,9 corneal ulcéra tion,10 or episcleral granulomas 11 caused by Nocardia organisms have occasionally been reported. In addition to our patient, we were
able to find reports of six other instances of intraocular nocardiosis. Two patients had bi lateral involvement. The Table summarizes the clinical features of these cases. Of the seven cases of intraocular nocardiosis, only one case of infection (Meyer and associ ates' 13 Case 1 ) was exogenous in origin. The other patients manifested ocular infections from apparent hematogenous (endogenous) spread of the nocardial organism. The Table confirms that intraocular nocar diosis occurs in immunologically compro mised patients. Two of the seven cases in volved immunosuppressed renal transplant patients, and four of the remaining five pa tients were debilitated—one postoperatively, one with jaundice, and two with cutaneous wounds. The eye findings at the time of infection included evidence of iridocyclitis with flare and cells, vitreitis, and frequently choroidal abscesses with overlying retinal detachment and degeneration. The organism was identi fied in the vitreous or proliferating along Bruch's membrane. Despite the sensitivity of Nocardia to sul-
572
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER, 1973
TABLE INTRAOCULAR NOCARDIOSIS Possible Predisposing Condition
Clinical Findings
Eye Pathology
Site of Nocardia
Case
Age
Eye
Davidson and Foerster"
46
L
Jaundice
Choroidal mass; later, iridocyclitis, vitreitis, retinal detachment with exudative choroiditis
Iridocyclitis, choroiditis, sub retinal abscess, retinal necrosis
Meyer and associates," Case 1
78
L
Cataract surgery
Iridocyclitis, vitreitis
Epithelial down- Vitreous growth, anterior chamber reaction, keratitis, scleritis, vitreitis, inflam matory cells on inner retina, and nervehead edema
Enucleation
Case 2
67
L
Gunshot wound of chest
Peripapillary chorioretinal inflammation
Subretinal ab Subretinal and scess, retinal de along Bruch's tachment and membrane degeneration, choroiditis
Death
Case 3
56
Bilateral
None
Bilateral chorio- Cyclitis, choroidal Along Bruch's Vision returned to 20/300 (RE) ; retinitis, propto- abscesses, scleritis, and in retina, keratitis (LE) sis (LE) cornea, and sciera evisceration (LE) (LE)
Burpee and Starke»
20
Bilateral
War wound lower Conjunctival extremity erythema, posterior synechiae, exudative retinal detachment (RE); chorioretinal exudates (LE)
Panijayanond and associ ates16
50
L
Immunosuppressed renal transplant patient
Cloudy subretinal Necrotizing mass; later, chorioretinitis opaque "posterior" chamber
Present case
40
R
Immunosuppressed renal transplant patient
Chorioretinal abscesses
fonamides, the outcome in the nine eyes was poor. Five of the nine eyes required enucle ation or evisceration, and only two eyes re tained useful vision. This poor prognosis may be related to delayed diagnosis or per haps to poor intraocular penetration of the antibiotic. Despite several weeks of high doses of sulfisoxazole, our patient still showed proliferation of the organism along Bruch's membrane. Although N. astéroïdes is not a common intraocular pathogen, this diagnosis should be suspected in debilitated patients, particu
Subretinal
Iritis pupillary Vitreous membrane, ciliary body detachment, vitreitis, neuritis, choroiditis, retinal detachment (RE)
Vitreous
Choroiditis, sub Along Bruch's retinal abscesses, membrane exudative retinal detachment, and retinal necrosis
Outcome Enucleation
Enucleation (RE) ; lesions healed (LE)
Enucleation
Death
larly those on immunosuppressive therapy with uveitis. Vitreitis or choroiditis are par ticularly suggestive of nocardiosis. The addi tional presence of pulmonary, cerebral, or skin lesions may be helpful in making the di agnosis. Since identifying the organism may be difficult either on smear or culture, and since Nocardia is susceptible to sulfonamides, treatment with antibiotics should be gin immediately in patients in whom there is a high index of suspicion. Such treatment may significantly decrease the mortality and morbidity of this infection.
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573
5. Chandler, J. W., Kalina, R. E., and Milam, D. F. : Coccidiodal choroiditis following renal trans A 40-year-old renal transplant recipient plantation. Am. J. Ophthalmol. 74:1080, 1972. 6. DeVenecia, G., ZuRhein, G. M., Pratt, M. V., developed cutaneous nocardiosis while on and Kisken, W. : Cytomegalic inclusion retinitis in immunosuppressive medications. Response an adult. Arch. Ophthalmol. 86:44, 1971. 7. Young, L. S., Armstrong, D., Blevins, A., and to sulfisoxazole was good, but three months Lieberman, P. : Nocardia astéroïdes infection com later, systemic nocardiosis, including unilat plicating neoplastic disease. Am. J. Med. 50:356, eral chorioretinal abscesses, appeared. The 1971. 8. Newmark, E., Polack, F. M., and Ellison, A. patient died despite intensive antibiotic ther C. : Report of a case of Nocardia astéroïdes keratiapy. Postmortem examination of the in tis. Am. J. Ophthalmol. 72:813, 1971. volved eye demonstrated proliferation of the 9. Benedict, W. L., and Iverson, H. A. : Chronic Nocardia along Bruch's membrane with cho keratoconjunctivitis associated with Nocardia. Arch. Ophthalmol. 32:89, 1944. rioretinal abscess formation. 10. Schardt, W. M., Unsworth, A. C, and Hayes, C. V. : Corneal ulcer due to Nocardia astér oïdes. Am. J. Ophthalmol. 42:303, 1956. REFERENCES 11. Henderson, J. W., Wellman, W. E., and 1. Hill, R. B., Rowlands, D. T., and Rifkind, D. : Weed, L. A. : Nocardiosis of the eye. Report of Infectious pulmonary disease in patients receiving case. Mayo Clin. Proc. 35 :614, 1960. immunosuppressive therapy for organ transplanta 12. Davidson, S., and Foerster, H. C. : Intraocu tion. N. Engl. J. Med. 271:1021, 1964. lar nocardial abscess, endogenous. Trans. Am. 2. Rifkind, D., Marchioro, T. L., Schneck, S. A., Acad. Ophthalmol. Otolaryngol. 71:847, 1967. 13. Meyer, S. L., Font, R. L., and Shaver, R. P. : and Hill, R. B. : Systemic fungal infections compli cating renal transplantation and immunosuppressive Intraocular nocardiosis. Arch. Ophthalmol. 83:536, 1970. therapy. Am. J. Med. 43:28, 1967. 14. Burpee, J. C, and Starke, W. R. : Bilateral 3. Hill, R. B., Dahrling, B. E., Starzl, T. E., and Rifkind, D. : Death after transplantation. Am. J. metastatic intraocular nocardiosis. Arch. Ophthal mol. 86:666, 1971. Med. 42:327, 1967. 4. Cohen, M. L., Weiss, E. B., and Monaco, A. 15. Panijayanond, P., Olsson, C. A., Spivack, M. P. : Successful treatment of Pneumocystis carinii L., Schmitt, G. W., Idelson, B. A., Sachs, B. J., and and Nocardia astéroïdes in a renal transplant pa Nabseth, D. C. : Intraocular nocardiosis in a renal tient. Am. J. Med. 50:269, 1971. transplant patient. Arch. Surg. 104:845, 1972. SUMMARY
NOCARDIOSIS
L E E M . J A M P O L , M.D., BARRY S. S T R A U C H , M.D., A N D D A N I E L M . A L B E R T , M . D .
New Haven, Connecticut With the increasing use of immunosuppressive agents in patients receiving organ transplants and intensive chemotherapy in patients with neoplastic disease, infections with opportunistic organisms are becoming disturbingly common.1-7 In debilitated pa tients in general, infections with opportunis tic fungi (e.g., Candida, Aspergillus), vi ruses (e.g., cytomegalovirus), and other or ganisms (e.g., Pneumocystis carinii) are be ing frequently reported. Nocardia astér oïdes has also become a significant pathogen in many of these patients, and the eye find ings may be a valuable clue in diagnosing nocardial infection. We describe a renal trans plant patient who developed systemic nocardiosis, and in whom chorioretinal abscesses were a striking clinical finding. Despite vig orous antibiotic therapy the patient died. Postmortem examination allowed histopathologic evaluation of the eye changes and cor relation with the clinical findings. CASE REPORT
A 40-year-old white man was in good health un til 1967 when he had the onset of fatigue and arthralgias. A pulmonary nodule, proteinuria, and hematuria were present. A renal biopsy was inter preted as being consistent with Wegener's granulomatosis. Eye evaluation at that time revealed bilat eral episcleritis that subsequently improved with topical corticosteroid administration. Other findings on the eye examination were within normal limits. The patient received systemic corticosteroids and azathioprine and showed initial improvement. By 1969, however, progressively deteriorating renal function necessitated chronic hemodialysis. In No vember 1971, he received a cadaveric renal trans plant, and after an initial period of acute tubular From the Department of Ophthalmology and Visual Science, and the Department of Medicine, Yale University School of Medicine, New Haven, Connecticut. This study was supported in part by Public Health Service Grant EY-00002, Research to Prevent Blindness, Inc., and the Connecticut Lions Eye Research Foundation, Inc. Reprints requests to Lee M. Jampol, M.D., Yale University School of . Medicine, Department of Ophthalmology, New Haven, CT 06510.
necrosis, his renal function improved. Immunosuppressive therapy to prevent rejection of the trans plant included azathioprine, 2 to 3 mg/kg, and high doses of prednisone. Therapy was continued, and the transplanted kid ney functioned well until February 1972, when he was admitted to Yale-New Haven Hospital with chills and fever, There were tender erythematous abscesses on the left forearm and two areas on his back. Nocardia astéroïdes was seen on smear from these lesions and grew out in culture. Treatment with sulfadiazine, 8 g/day, was started, and after one week, sulfisoxazole, 8 g/day, was added. One week later the sulfadiazine was stopped, and sulfi soxazole, 16 g/day, was continued for five addi tional weeks. At this point a generalized rash devel oped which resolved with discontinuation of the sul fisoxazole. The skin abscesses healed well, and there was no evidence of dissemination of the infection. On May 3, 1972, the patient was readmitted because of deterioration of his renal function. A renal biopsy showed acute rejection. Treatment with high doses of prednisone was reinstituted. Two weeks later he began having daily febrile spikes, and one week following this, complained of blurring of vi sion. Eye evaluation on May 24, showed the visual acuity to be 20/60 in the right eye and 20/25 in the left eye. Findings on external and slit-lamp exami nations were within normal limits as were the intra ocular pressures. Examination of the right fundus demonstrated four elevated white-yellow choroidal infiltrates with overlying retinal detachment and retinal hemorrhages (Fig. 1). The appearance of the left fundus was normal. A repeat chest x-ray (Fig. 2) showed multiple nodules in both lungs, and an open lung biopsy revealed miliary abscesses. Cul tures grew out N. astéroïdes. Despite therapy with sulfisoxazole, ampicillin, and streptomycin, the patient's condition deterio rated, and he became comatose. We examined the fundi daily, and the choroidal lesions remained es sentially unchanged until the patient's death on June 11. General pathologic findings—Autopsy revealed bi lateral scarred kidneys and evidence of mild rejec tion in the transplanted kidney. The transplant showed perirenal inflammatory changes, but no or ganisms were isolated from the transplant. In addi tion, the liver and lungs contained cerebral microabscesses and old healed granulomas, which were ster ile on smear and culture. Nocardia astéroïdes was identified only in the prostate and the right eye. Pathologic findings in the eye—Both eyes were sub mitted to the Yale Eye Pathology Laboratory. Upon sectioning the right eye, we saw four distinct
568
VOL. 76, NO. 4
569
INTRAOCULAR NOCARDIOSIS
Fig. 1 (Jampol, Strauch, and Albert). Fundus photograph demonstrating chorioretinal abscess ad jacent to the disk. The retina overlying the lesion is elevated with areas of retinal hemorrhage. chorioretinal infiltrates in the posterior pole (Fig. 3). Microscopic sections of the right eye revealed an unremarkable cornea, anterior chamber, lens, iris, and ciliary body. The vitreous cavity was clear. The choroid demonstrated areas of marked thickening with infiltration by large numbers of lymphocytes and plasma cells, and occasional polymorphonuclear leukocytes (Figs. 4 and 5). Some choroidal hemor rhage was seen. Overlying the choroidal abscesses, Bruch's membrane was largely intact but with dis rupted pigment epithelium (Fig. 5). The retina overlying the abscesses was detached and showed
Fig. 3 (Jampol, Strauch, and Albert). Appear ance of two of chorioretinal abscesses (arrows). The lower abscess corresponds to the lesion seen in Figure 1. foci of retinal necrosis with disorganization and de generation. In areas, beneath the detached neural retina, and also beneath the pigment epithelium, were chronic inflammatory cells and cellular debris. Brown-Brenn stains demonstrated a filamentous or ganism proliferating along Bruch's membrane with extension into the subretinal space (Fig. 6). Histologically the organism was consistent with N. astér oïdes. Occasional organisms were seen in the cho roid itself. The optic nervehead was edematous with involvement of the surrounding nerve fiber layer. The choroid and retina in areas not involved by the Nocardia organisms were completely normal. The sciera was unremarkable. The left eye was normal grossly and microscopically. The diagnosis was (1) N. astéroïdes choroidal abscesses of the right eye, and (2) exudative de tachment of the overlying retina with retinal necro sis. DISCUSSION
Fig. 2 (Jampol, Strauch, and Albert). Chest x-ray showing bilateral nocardial pneumonitis.
Nocardia astéroïdes is a filamentous Gram-positive organism that was originally classified as a fungus. Recently Nocardia, as well as its relative Actinomyces, have been recognized to be more closely related to the bacteria. Although Nocardia organisms can easily be isolated from soil, they were rarely noted to be pathogenic until recent years. In fection by this organism is usually seen in debilitated patients, especially those with
570
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER, 1973
Fig. 4 ( Jampol, Strauch, and Albert). Low-power view of a nocardial lesion. Note the choroidal and ret inal portions of the abscess. Arrow indicates Bruch's membrane. In this section, the retina is largely replaced by inflammatory cells and cellular debris (hematoxylin-eosin, XlOO).
Fig. S (Jampol, Strauch, and Albert). Higher power view of the abscess. The retina in this section is largely intact, although it is detached. The pigment epithelium is disrupted centrally. R indicates retina; S, subretinal debris; P, pigment epithelium; B, Bruch's membrane; and C, choroid (hematoxylin-eosin, X400).
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Fig. 6 (Jampol, Strauch, and Albert). Proliferation of Nocardia along retinal side of Bruch's membrane (Brown-Brenn, X 1,000).
cancer, dysproteinemias, disseminated lupus, and other conditions associated with im paired immunologie mechanisms.7 Patients on systemic corticosteroids and other immunosuppressives, particularly renal transplant patients, have a significant incidence of no cardial infection.1"4 The clinical manifestations of nocardial infection frequently include bronchopneumonia or lobar pneumonia, and disseminated abscesses often appear, particularly in the skin, brain, liver, and scrotum. Although it is uncertain whether Nocardia can be a con taminant, when the organism is isolated it is usually considered pathogenic. Unfortu nately cultures and Gram stains can initially be negative despite active nocardial disease. When the organism is the cause of infection, patients often respond well to sulfonamide therapy. Although Nocardia shows a sensi tivity in vitro to other antibiotics, clinically these have proved disappointing. Keratitis, 8 conjunctivitis,9 corneal ulcéra tion,10 or episcleral granulomas 11 caused by Nocardia organisms have occasionally been reported. In addition to our patient, we were
able to find reports of six other instances of intraocular nocardiosis. Two patients had bi lateral involvement. The Table summarizes the clinical features of these cases. Of the seven cases of intraocular nocardiosis, only one case of infection (Meyer and associ ates' 13 Case 1 ) was exogenous in origin. The other patients manifested ocular infections from apparent hematogenous (endogenous) spread of the nocardial organism. The Table confirms that intraocular nocar diosis occurs in immunologically compro mised patients. Two of the seven cases in volved immunosuppressed renal transplant patients, and four of the remaining five pa tients were debilitated—one postoperatively, one with jaundice, and two with cutaneous wounds. The eye findings at the time of infection included evidence of iridocyclitis with flare and cells, vitreitis, and frequently choroidal abscesses with overlying retinal detachment and degeneration. The organism was identi fied in the vitreous or proliferating along Bruch's membrane. Despite the sensitivity of Nocardia to sul-
572
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER, 1973
TABLE INTRAOCULAR NOCARDIOSIS Possible Predisposing Condition
Clinical Findings
Eye Pathology
Site of Nocardia
Case
Age
Eye
Davidson and Foerster"
46
L
Jaundice
Choroidal mass; later, iridocyclitis, vitreitis, retinal detachment with exudative choroiditis
Iridocyclitis, choroiditis, sub retinal abscess, retinal necrosis
Meyer and associates," Case 1
78
L
Cataract surgery
Iridocyclitis, vitreitis
Epithelial down- Vitreous growth, anterior chamber reaction, keratitis, scleritis, vitreitis, inflam matory cells on inner retina, and nervehead edema
Enucleation
Case 2
67
L
Gunshot wound of chest
Peripapillary chorioretinal inflammation
Subretinal ab Subretinal and scess, retinal de along Bruch's tachment and membrane degeneration, choroiditis
Death
Case 3
56
Bilateral
None
Bilateral chorio- Cyclitis, choroidal Along Bruch's Vision returned to 20/300 (RE) ; retinitis, propto- abscesses, scleritis, and in retina, keratitis (LE) sis (LE) cornea, and sciera evisceration (LE) (LE)
Burpee and Starke»
20
Bilateral
War wound lower Conjunctival extremity erythema, posterior synechiae, exudative retinal detachment (RE); chorioretinal exudates (LE)
Panijayanond and associ ates16
50
L
Immunosuppressed renal transplant patient
Cloudy subretinal Necrotizing mass; later, chorioretinitis opaque "posterior" chamber
Present case
40
R
Immunosuppressed renal transplant patient
Chorioretinal abscesses
fonamides, the outcome in the nine eyes was poor. Five of the nine eyes required enucle ation or evisceration, and only two eyes re tained useful vision. This poor prognosis may be related to delayed diagnosis or per haps to poor intraocular penetration of the antibiotic. Despite several weeks of high doses of sulfisoxazole, our patient still showed proliferation of the organism along Bruch's membrane. Although N. astéroïdes is not a common intraocular pathogen, this diagnosis should be suspected in debilitated patients, particu
Subretinal
Iritis pupillary Vitreous membrane, ciliary body detachment, vitreitis, neuritis, choroiditis, retinal detachment (RE)
Vitreous
Choroiditis, sub Along Bruch's retinal abscesses, membrane exudative retinal detachment, and retinal necrosis
Outcome Enucleation
Enucleation (RE) ; lesions healed (LE)
Enucleation
Death
larly those on immunosuppressive therapy with uveitis. Vitreitis or choroiditis are par ticularly suggestive of nocardiosis. The addi tional presence of pulmonary, cerebral, or skin lesions may be helpful in making the di agnosis. Since identifying the organism may be difficult either on smear or culture, and since Nocardia is susceptible to sulfonamides, treatment with antibiotics should be gin immediately in patients in whom there is a high index of suspicion. Such treatment may significantly decrease the mortality and morbidity of this infection.
VOL. 76, NO. 4
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