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 Table of Contents  
BRIEF COMMUNICATION
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 104-106

Disseminated nocardiosis in an immunocompetent adult with retinal abscess and endocardial mass


Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India

Date of Submission06-Mar-2016
Date of Acceptance28-Sep-2016
Date of Web Publication25-Apr-2017

Correspondence Address:
Chellappan Prasannakumary
Department of Ophthalmology, Government Medical College, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.205181

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  Abstract 

Nocardiosis is an opportunistic infection reported among immunocompromised subjects. Endophthalmitis secondary to hematogenous spread is a well-known sequel in such cases. In healthy individuals, ocular manifestations are limited to surface infections like keratitis. We report a case of endogenous endophthalmitis due to dissemination from cutaneous nocardiosis in a healthy adult who also had evidence of the right atrial nocardial mass.

Keywords: Abscess, cardiac mass, disseminated nocardiosis, endophthalmitis, immunocompetent, retinal abscess


How to cite this article:
Prasannakumary C, Babitha V, Raju KV, Swetha H. Disseminated nocardiosis in an immunocompetent adult with retinal abscess and endocardial mass. J Clin Ophthalmol Res 2017;5:104-6

How to cite this URL:
Prasannakumary C, Babitha V, Raju KV, Swetha H. Disseminated nocardiosis in an immunocompetent adult with retinal abscess and endocardial mass. J Clin Ophthalmol Res [serial online] 2017 [cited 2020 Oct 28];5:104-6. Available from: https://www.jcor.in/text.asp?2017/5/2/104/205181

Nocardiosis in immunocompetent subjects are rare and reported only in 15% cases of Nocardia infection.[1] Disseminated nocardiosis in immunocompetent is further rare and around 15 cases were found in PubMed search.[1] Coexistent endogenous endophthalmitis with ipsilateral cardiac chamber nocardial mass is not reported in literature. An attempt is made to report a case of multifocal cutaneous nocardiosis in a healthy adult with dissemination to the right eye (RE) and right atrium.


  Case Report Top


A 28-year-old previously healthy male farmer presented with a complaint of blurred vision in RE of 2 weeks duration and multiple abscesses in the right thigh. He gave a history of low-grade fever for 1 month. On examination, RE showed features of iritis, vitritis, optic disc edema, and multiple subretinal abscesses suggestive of endophthalmitis [Figure 1] and [Figure 2]. Left eye (LE) was normal. The best-corrected visual acuity (BCVA) in the RE was 20/40 Snellen and BCVA in the LE was 20/20. He had no anemia, lymphadenopathy, hepatosplenomegaly. He had not undergone any organ transplantation and was not on steroids or chemotherapy. He was not an alcoholic. Total blood examination was normal except for neutrophilia (total count 9300, polymorphs 90%, and erythrocyte sedimentation rate 10 mm). Fasting blood sugar, rheumatoid factor, antinuclear antibody, double-stranded deoxyribonucleic acid antibody, venereal disease research laboratory test, renal function tests, liver function tests, human immunodeficiency virus test, hepatitis B virus surface antigen, hepatitis C virus surface antigen were normal.

Chest X-ray revealed right-sided pleural effusion. There was no evidence of consolidation. Cardiac workup was done in view of exertional breathlessness. Echocardiography revealed a linear nonmobile calcified mass in the right atrium of 30 mm × 14 mm size suggestive of Nocardia granuloma which is confirmed by computed tomography thorax [Figure 3]. Culture of pus drained from thigh abscess confirmed nocardiosis [Figure 4] and [Figure 5]. Subspecies identification and drug sensitivity were not done due to lack of availability in our institution and lack of affordability of patient.
Figure 1: Disc edema with subretinal abscess

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Figure 2: Vitritis with sub retinal abscess

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Figure 3: Echocardiography showing nocardial granuloma in atrium

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Figure 4: Blood agar with nocardial growth

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Figure 5: Microscopy with branching filaments of Nocardia

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The patient was treated with intravenous injection of Amicip 500 mg once daily (Cipla Limited) and Magnex-sulbactam 500 mg and cefoperazone 500 mg (Pfizer Limited) three times daily for 3 weeks and topical prednisolone acetate 4 hourly (PRED FORTE-Allergen India Limited) amikacin 6 hourly (Aminogen-Jawa Pharmaceuticals) and homatropine hydrobromide 2% 8 hourly (Warren Indoco Remedies). On review after 2 weeks, his vision improved to 20/32 and anterior uveitis decreased. Retinal abscess and vitritis were resolving. Despite the temporary improvement, his general condition worsened, and he succumbed to death within 1 month of diagnosis.


  Discussion Top


Nocardia endophthalmitis is a diagnosis of exclusion. It is associated with disseminated nocardiosis, especially in immunocompromised individuals.[2],[3] The primary foci are lung and brain.[4],[5] There are isolated case reports of mediastinal or pericardial nocardiosis in the literature. Mediastinal involvement is often secondary to pulmonary foci or as in ocular nocardiosis due to hematogenous spread of organism.[3],[6] Concurrent retinal abscess with endocardial involvement is not described in literature.

Nocardia is a ubiquitous organism found in soil is rich in organic matter. Nocardia is a Gram-positive, rod-shaped, and filamentous acid-fast bacteria belonging to the suborder, Corynebacterineae, of the phylum Actinobacteria. The most common pathogenic strain is Nocardia asteroides complex. It is the organism isolated from pulmonary foci which constitute 70% of human nocardiosis.[7]

Nocardia brasiliensis associated with multiple and deep abscesses called actinomycetoma.[7],[8] Nocardial infection can erode into blood vessels and spread to other sites such as central nervous system, kidneys, joints, bone, retina, and the heart.[7],[9]

Deep and disseminated nocardial infection with end-organ infiltration is described among immunocompromised subjects with underlying malignancy, HIV, renal transplant, diabetes, or long-standing steroid treatment. Among immunocompetent individuals, Nocardia causes localized lesions such as cellulitis, abscesses, and isolated endophthalmitis.[2],[3] Isolated cutaneous disease follows direct inoculation of the organism as a result of trauma, surgery, vascular catheters, animal scratches, or bites.[9] Usually, ocular infection caused by Nocardia is keratitis.[2] Nocardial endophthalmitis is a rare disease usually reported after ocular trauma or surgery.[4] Endogenous endophthalmitis is associated with disseminated nocardiosis from pulmonary or cerebral foci.[4],[5]

The involvement of the right atrium and RE suggest spread of the organism from the cutaneous site through bloodstream.

Containment of disease depends on humoral immune response mediated by macrophages in immunocompetent individuals.[9] Dissemination occurs in the context of altered immunity, primary or acquired. The occurrence of nocardiosis in the apparently healthy population may be due to undetected deficiency or alteration in the immune pathway.

Early diagnosis is crucial for reducing disease-related morbidity. Although the mortality rates are low, risk of end-organ dysfunction such as seizures, cardiac, and pulmonary complications exist. The drug of choice for nocardiosis is trimethoprim-sulfamethoxazole. Minocycline, amikacin, imipenem, and linezolid are also effective against nocardiosis. Surgical treatment of nocardiosis includes debridement of lesion.[7]

Isolation of Nocardia is difficult due to the fastidious nature of the organism, its slow growth in culture media and need for an invasive procedure for obtaining an adequate specimen. With myriad clinical spectrum, antibiotic susceptibility, and associated multiorgan dysfunction-related mortality, subspecies identification is a necessity for understanding the disease course. In addition to the classic laboratory methods of staining and culture, molecular studies like sequence analysis of the 16S ribosomal (r) RNA gene have to be utilized.[10] Species identification was not done in our case as the facility is not available in our institute.

Our case was unique as it was in a young immunocompetent person with concurrent retinal abscess and endocardial mass suggestive of chronicity.


  Conclusion Top


Nocardiosis in a healthy person is often misdiagnosed because of its rarity and nonspecific presentations and need a high index of suspicion. Early treatment can prevent chronicity and dissemination in high-risk individuals. Mutagenic changes in Nocardia species may be responsible for increasing trend of nocardiosis in immunocompetent individuals. Undetected causes of primary immunodeficiency have to be evaluated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Budzik JM, Hosseini M, Mackinnon AC Jr., Taxy JB. Disseminated Nocardia farcinica: Literature review and fatal outcome in an immunocompetent patient. Surg Infect (Larchmt) 2012;13:163-70.  Back to cited text no. 1
    
2.
Shobana CS, Sreekumar H, Aiswariya P. BMC Infect Dis 2014;14(Suppl 3):2.  Back to cited text no. 2
    
3.
Jinno S, Jirakulaporn T, Bankowski MJ, Kim W, Wong R. Rare case of Nocardia asteroides pericarditis in a human immunodeficiency virus-infected patient. J Clin Microbiol 2007;45:2330-3.  Back to cited text no. 3
    
4.
de Silva T, Evans C, Mudhar HS, Rennie I, Green ST. Isolated endogenous endophthalmitis secondary to Nocardia spp in an immunocompetent adult. J Clin Pathol 2006;59:1226.  Back to cited text no. 4
    
5.
Ishibashi Y, Watanabe R, Hommura S, Koyama A, Ishikawa T, Mikami Y. Endogenous Nocardia asteroides endophthalmitis in a patient with systemic lupus erythematosus. Br J Ophthalmol 1990;74:433-6.  Back to cited text no. 5
    
6.
Salazar MN, Wray D, Denlinger C, Srinivas T, Thomas B, Posadas A. Mediastinal mass and pericardial tamponade in a renal transplant recipient: A rare case of Nocardia infection. Am J Case Rep 2013;14:295-9.  Back to cited text no. 6
    
7.
Das AK, Nandy S, Dudeja M, Tiwari R, Alam S. The incidence of nocardiosis at pulmonary and extra – Pulmonary sites. J Clin Diagn Res 2013;7:1427-9.  Back to cited text no. 7
    
8.
Almaguer-Chávez JA, Welsh O, Lozano-Garza HG, Said-Fernández S, Romero-Díaz VJ, Ocampo-Candiani J, et al. Decrease of virulence for BALB/c mice produced by continuous subculturing of Nocardia brasiliensis. BMC Infect Dis 2011;11:290.  Back to cited text no. 8
    
9.
Beaman BL, Beaman L. Nocardia species: Host-parasite relationships. Clin Microbiol Rev 1994;7:213-64.  Back to cited text no. 9
    
10.
Taj-Aldeen SJ, Deshmukh A, Doiphode S, Wahab AA, Allangawi M, Almuzrkchi A, et al. Molecular identification and susceptibility pattern of clinical Nocardia species: Emergence of Nocardia crassostreae as an agent of invasive nocardiosis. Can J Infect Dis Med Microbiol 2013;24:e33-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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