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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 34  |  Issue : 1  |  Page : 50-52

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


1 Oculoplasty and Ocular Oncology Services, Dr Shroff's Charity Eye Hospital, New Delhi, India
2 Ocular Microbiology and Pathology Services, Dr Shroff's Charity Eye Hospital, New Delhi, India
3 Pediatric Services, Dr Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India

Date of Submission12-May-2018
Date of Decision07-Mar-2019
Date of Acceptance11-Sep-2019
Date of Web Publication26-Nov-2020

Correspondence Address:
Sweety Tiple
1504, Tower 21, Lotus Boulevard, Sector 100, Noida - 201 304, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-4534.301164

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  Abstract 


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.

Keywords: Nocardia endophthalmitis, orbital abscess, orbital imaging, pediatric


How to cite this article:
Tiple S, Das S, Gandhi A, Kimmatkar P. Nocardia endophthalmitis in a child: Distinct clinical and imaging features on orbital CT scan. Saudi J Ophthalmol 2020;34:50-2

How to cite this URL:
Tiple S, Das S, Gandhi A, Kimmatkar P. Nocardia endophthalmitis in a child: Distinct clinical and imaging features on orbital CT scan. Saudi J Ophthalmol [serial online] 2020 [cited 2021 Nov 30];34:50-2. Available from: http://www.sjo.org/text.asp?2020/34/1/50/301164




  Introduction Top


Trauma is the most common cause of endophthalmitis in children with incidence reported between 2% and 70%[1],[2] most commonly due to Streptococci and Staphyloccal species.[3],[4]

The diagnosis of post-traumatic endophthalmitis in children is often delayed due to the inability of the child to vocalize their complaints and delay on the part of the parents especially if the injury was trivial. Primary Nocardia endophthalmitis in immunocompetent individual is most likely post-traumatic.[5],[6] Nocardia, itself, is a very rare cause of endophthalmitis in children with only one case reported in literature till the submission of this case report.[7] We describe a rare case of Nocardia endophthalmitis in a toddler with very unique orbital CT scan findings.


  Case Report Top


A 15-month-old boy presented with complains of pain, redness and photophobia in the left eye since 2 months. There was a vague history of trauma, following which the parents noticed the symptoms. The child was healthy with normal developmental milestones and was well immunized for age. Visual acuity could not be assessed due to extreme photophobia. The left eye had diffuse corneal haze with blood staining. There was circumciliary congestion and anterior chamber showed hyphema obstructing the fundus view. The intraocular pressure was 26 mmHg. The other eye was normal. Ultrasound B-scan showed few low reflective dot echoes with an attached retina with no evidence of any intraocular foreign body, mass lesion or calcification. With a working diagnosis of post-traumatic hyphema with secondary glaucoma, the child was started on topical antiglaucoma and cycloplegics. But the condition of the child acutely worsened within a week. The left eye progressed to proptosis, lid edema and restriction of movement. Anterior chamber was filled with blood tinged fibrinous exudates and a scleral abscess was noted at the infero-temporal limbus [Figure 1]. Repeat B-scan revealed plenty of medium reflective membranous echoes with collection of sub-Tenons fluid (positive T sign).
Figure 1: Left eye showing lid edema, diffuse conjunctival congestion and a scleral abscess at the temporal limbus. Cornea appears hazy and anterior chamber is full of blood stained fibrinous exudates

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CT-scan orbit revealed proptosis with increased preseptal soft tissue edema. Multiple hyperdense membranes/septae were seen in the mid and posterior vitreous suggestive of multiple abscess in the vitreous. Increased thickening of the sclera and choroid was noted. There was no evidence of an intraocular mass lesion or calcification. On IV contrast, there was a ring enhancing lesion in the intraconal space just behind the globe suggestive of an intraconal abscess [Figure 3]a and [Figure 3]b. A diagnosis of panophthalmitis was made and a pediatrician consult was sought to rule out any systemic foci of infection for endogenous etiology. Systemic examination and investigations were negative.
Figure 2: (a-c): On modified Ziehl-Neelsen stain (a), Nocardia appears as partially acid fast beaded branching filamentous bacilli. Gram stain showing mildly Gram positive beaded filaments indicating Nocardia. On Chocolate Agar (b), colonies of Nocardia appear as white powdery growth which was seen after a period of 3 days

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Figure 3: (a and b): CT scan orbit, Axial view (a) depicting gross proptosis with preseptal soft tissue edema along with thickening of the sclera and the choroid in the left globe. Multiple membrane-like hyperdense septae are seen in the posterior vitreous cavity suggestive of multiple abscess formation along with a ring enhancing lesion on contrast enhancement is seen in the intraconal space just posterior to the globe. Sagittal section (b) passing through the left globe demonstrates the hyperdense membrane like septae in the mid and the posterior vitreous

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As there was no improvement in the eye condition after 24 h of systemic broad spectrum antibiotics, evisceration was planned. Intraocular contents were sent for microbiology and histopathologic evaluation.

On Gram stains, mildly Gram-positive beaded filaments more prominent in the modified Ziehl-Neelsen stain with 1% sulphuric acid were noted [Figure 2]a and [Figure 2]b. Chalky white colonies grew on the Chocolate agar 3 days after inoculation [Figure 2]c. Smear from culture confirmed the presence of Nocardia. Based on the sensitivity pattern the patient was started on oral combination of Sulphamethoxazole (8 mg/kg/day) + Trimethoprim (50 mg/kg/day) along with topical Moxifloxacin. The child had a healthy socket with no evidence of local recurrence at 1 week and 1 month follow-up. The antibiotics were continued for 10 weeks. He showed no signs of systemic or local recurrence till his last follow-up at 1 year.


  Discussion Top


Nocardia is a gram positive, branching filamentous aerobe, saprophytic in nature and is ubiquitously found in soil and air. Primary nocardial endophthalmitis in immunocompetent individual is mostly post-traumatic.[7] Endogenous Nocardia endophthalmitis is usually secondary to disseminated nocardiosis.[5],[6] Nocardia endophthalmitis (endogenous or post-traumatic) is associated with severe morbidity and mortality.

To the best of our knowledge, there is only a single case report of a 5 year old immunocompetent child with post-traumatic Nocardia endophthalmitis in literature. The child was misdiagnosed as a case of recurrent uveitis with traumatic cataract and later presented with features of endophthalmits secondary to Nocardia.[7] This may be due to the slow growing nature of the organism. Our patient too was initially misdiagnosed as traumatic hyphema and vitreous hemorrhage, as features of active infection were absent at presentation.

Identification of Nocardia species is based on the typical staining and growth characteristics. Nocardia is a Gram-positive branching, beaded filamentous bacilli and is faintly AFB positive with modified 0.5–1% Ziehl-Neelsen stain. Chalky white growth on conventional media like Sheep blood/Chocolate agar helps in confirming the diagnosis. Growth is often delayed with an average of 2–7 days on routine media.[8] We could not perform the biochemical and genotyping tests for species identification due to lack of facilities. Systemic evaluation is of utmost importance as ocular manifestation in Nocardia infection are known to precede systemic disease in almost half of the cases.[8],[9],[10],[11] In our patient, the site of primary inoculation was most likely the eye due to trauma, hence we could not find any evidence of systemic involvement even at presentation and follow-up.

Exogenous Nocardia endophthalmitis following surgery is known to cause loacalised inflammation in the anterior chamber with relative sparing of the posterior segment.[5],[7],[8] However in our patient, both the anterior and posterior segments were involved with predominant vitreous involvement which is rarely seen in Nocardia endophthalmitis probably pointing towards a deep penetrating trauma.

Nocardia infection is characterized by abscess formation in the involved organ.[8],[9] Yu et al. were the first to demonstrate the evolving CT and MRI features of a patient with Nocardia endophthalmitis progressing to panophthalmitis.[10] The features of proptosis with preseptal soft tissue edema, presence of multiple abscesses in the vitreous cavity on orbital CT scan, although similar, were more advanced in our patient. However, the ring enhancing intraconal abscess noted in our patient has not been described previously. [Figure 3]a and [Figure 3]b. Systemic Co-trimoxazole remains the first line of therapy. Our patient responded very well and did not show any sign of local or systemic recurrence during the follow-up period of 1 year.

To conclude, Nocardia endophthalmitis is a rare but serious infection of the eye leading to severe mortality and morbidity. Delay in presentation after trauma may lead to disruption of tissue anatomy making the diagnosis and management more complicated. Post-traumatic endophthalmitis in children must be managed aggressively by imaging and early intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan S, Athwal L, Zarbin M, Bhagat N. Pediatric infectious endophthalmitis: A review. J Pediatr Ophthalmol Strabismus 2014;51:140-53.  Back to cited text no. 1
    
2.
Bansal Pooja, Venkatesh Pradeep, Sharma Yograj. Posttraumatic endophthalmitis in children: Epidemiology, diagnosis, management, and prognosis. Semin Ophthalmol 2016;1-9. https://doi.org/10.1080/08820538.2016.1238095 [Epub ahead of print].  Back to cited text no. 2
    
3.
Al-Rashaed SA, Abu El-Asrar AM. Exogenous endophthalmitis in pediatric age group. Ocul Immunol Inflamm. 2006;14:285-92.  Back to cited text no. 3
    
4.
Good WV, Hing S, Irvine AR, et al. Postoperative endophthalmitis in children following cataract surgery. J Pediatr Ophthalmol Strabismus 1990;27:283-5.  Back to cited text no. 4
    
5.
Decroos FC, Garg P, Reddy AK, et al. Hyderabad endophthalmitis research group optimizing diagnosis and management of Nocardia keratitis, scleritis, and endophthalmitis: 11-year microbial and clinical overview. Ophthalmology 2011;118:1193-200.  Back to cited text no. 5
    
6.
Sridhar MS, Gopinathan U, Garg P, et al. Ocular Nocardia infections with special emphasis on Cornea. Surv Ophthalmol 2001;45:361-78.  Back to cited text no. 6
    
7.
Compte RB, Martínez-Osorio H, Carrasco G, et al. Traumatic endophthalmitis caused by Nocardia kruczakiae in a patient with traumatic eye injury. Ophthalmic Inflamm Infect 2015;5(1):36. https:// doi.org/10.1186/s12348-015-0067-7 [Epub 2015 Nov 25].  Back to cited text no. 7
    
8.
Ferry AP, Font RL, Weinberg R, et al. Nocardial endophthalmitis: Report of two cases studied Histopathologically. Br J Ophthalmol 1988;72:55-61.  Back to cited text no. 8
    
9.
Silva RA, Young R, Sridhar J, Nocardia Study Group. Nocardia choroidal abscess: Risk factors, treatment strategies, and visual outcome. Retina 2015;35:2137-46.  Back to cited text no. 9
    
10.
Yu E, Laughlin S, Kassel EE, Messner HA, Yucel YH. Nocardial endophthalmitis and subretinal abscess: CT and MR imaging features with pathologic correlation: A case report. AJNR Am J Neuroradiol 2005;26:1220-2.  Back to cited text no. 10
    
11.
Dave VP, Pathengay A, Sharma S, et al. Diagnosis, clinical presentations, and outcomes of Nocardia endophthalmitis. Am J Ophthalmol 2019;197:53-8.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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