Correspondence Daniel E. Maidana, Silvia Sanz, Juan Lillo, Jorge Arruga Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain Correspondence to: Daniel E. Maidana, MD: [email protected]
REFERENCES 1. Postel EA, Pulido JS, McNamara JA, Johnson MW. The etiology and treatment of macular detachment associated with optic nerve pits and related anomalies. Trans Am Ophthalmol Soc. 1998;96:73-88, discussion 88-93.
Pulmonary nocardiosis initially manifesting as endogenous endophthalmitis Endogenous endophthalmitis is a rare sequela of pulmonary nocardiosis. We present a case of pulmonary nocardiosis that
2. Zumbro DS, Jampol LM, Folk JC, Olivier MMG, Anderson-Nelson S. Macular schisis and detachment associated with presumed acquired enlarged optic nerve head cups. Am J Ophthalmol. 2007;144:70-4. 3. Sugar HS. An explanation for the acquired macular pathology associated with congenital pits of the optic disc. Am J Ophthalmol. 1964;57:833-5. 4. Spaide RF, Costa DL, Huang SJ. Macular schisis in a patient without an optic disk pit optical coherence tomographic findings. Retina. 2003;23:238-40. 5. Doyle E, Trivedi D, Good P, Scott RA, Kirkby GR. High-resolution optical coherence tomography demonstration of membranes spanning optic disc pits and colobomas. Br J Ophthalmol. 2009;93:360-5. Can J Ophthalmol 2014;49:e56–e59 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.01.003
initially manifested as endogenous endophthalmitis and showed an appearance simulating choroidal metastatic disease. Nocardia infection should be considered in any patient with atypical lung nodules and panuveitis, particularly in those with immune deficiency.
Fig. 1 — External photograph of left eye on presentation demonstrates injected conjunctiva with a clear cornea and an approximately 1-mm hypopyon (upper left). Fundus photograph of the left eye on presentation shows dense vitritis. The optic nerve (arrow) and a white round lesion along the inferior arcade (chevron, upper right) are visible. B-scan ultrasonography of left eye discloses vitreous debris with a deep retinal elevation appearing irregular and with a cleft overlying the normal choroid (lower left). A-scan ultrasound of left eye discloses medium echoes within the lesion (lower right). CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
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Correspondence
Fig. 2 — CT of the chest demonstrates a 16 8-mm solid lesion (arrow) in the medial portion of the left upper lobe (top panels). Another lesion (chevron) in the medial portion of the anterior segment of the right upper lobe measures 12 mm in diameter (bottom panels).
Fig. 3 — Histopathology discloses disorganized retina architecture with multiple retinal microabscesses. Gram stain discloses branching, gram-positive rods. (Left) Hematoxylin and eosin stain. Original magnification 10. (Right) Gram stain. Original magnification 50.
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Correspondence An 80-year-old white male presented with a 1 week history of floaters, decreased vision, and pain in the left eye. He had no ocular history. His medical history was significant for myelodysplastic syndrome with chronic anemia diagnosed 2 years previously. Other medical conditions included cardiovascular disease, hypertension, rosacea, and osteoarthritis. His medications included doxycycline, felodipine, meloxicam, clonazepam, and simvastatin. On review of systems, he noted occasional dyspnea on exertion for 2 weeks. He denied fevers, weight changes, night sweats, or internal artificial devices. He was a nonsmoker and consumed a moderate amount of alcohol weekly. On examination, best corrected visual acuity was 20/30 OD and count fingers in the left eye. Pupils were 3 mm and reactive in each eye without relative afferent pupillary defect. The right eye showed a moderate cataract but was otherwise unremarkable. The left eye demonstrated poor dilation with
moderate conjunctival injection, clear cornea, moderate cataract, and a shallow inferior hypopyon. Fundus examination of the left eye revealed dense vitritis with a round, white mass along the inferior retinal vascular arcade (Fig. 1) that appeared solid on ultrasonography with overlying vitreous debris and history underlying intact choroid. CT of the chest (Fig. 2) disclosed a 16 8-mm spiculated soft-tissue nodule in the left upper lobe adjacent to the aortic arch. A second 12 12-mm nodule was observed within the right upper lobe adjacent to the aortic arch. Three blood cultures, lyme Western blot, fluorescent treponemal antibody (FTA), rapid plasma reagin (RPR), and HIV tests were negative. Transthoracic echocardiogram was normal. At this point, primary lung carcinoma with metastatic disease to the eye versus infectious process was suspected. A diagnostic vitrectomy with lensectomy and retinal photocoagulation was performed. During the operation,
Fig. 4 — CT of the chest 6 months after Figure 1 imaging demonstrates complete resolution of the lesion in the left upper lobe (arrow) and right upper lobe (chevron). Bibasilar atelectasis is also present, which was attributed to hypoventilation secondary to chest trauma. Notably, the patient is more kyphotic compared with Figure 2. CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
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Correspondence extensive retinal whitening and hemorrhage were observed along the inferior arcade. The vitreous fluid had negative KOH and Gram stains. Polymerase chain reaction for herpes simplex virus, varicella zoster virus, cytomegalovirus, and toxoplasmosis were negative. Flow cytometry was negative. Routine and fungal cultures were negative for growth at 1 week. Over 1 week, the extent of retinitis increased, and a retinal biopsy was performed and revealed gram-positive branching rods (Fig. 3). The initial vitreous fluid culture grew Nocardia farcinica on the 10th day. The patient was treated with oral sulfamethoxazoletrimethoprim double strength twice per day for 6 weeks. At the 3-month follow-up visit, the patient’s visual acuity was hand motions in the left eye, and the retinal infection resolved. Six months after initial presentation, the patient suffered an unrelated fall and underwent chest CT, which disclosed resolution of the previously documented lung lesions (Fig. 4). The final diagnosis was pulmonary nocardiosis with initial manifestation as endophthalmitis and with complete response to 6 weeks of oral sulfamethoxazole-trimethoprim therapy. Nocardia is a group of more than 50 species of grampositive, aerobic, filamentous, and weakly acid-fast bacteria. The taxonomy is challenging with many revisions over the past few decades.1 The species were originally referred to as Nocardia asteroides, but later found to be a group of bacteria with a heterozygous pattern of antimicrobial drug susceptibility.2 Nocardia is typically an opportunistic infection observed in patients with depressed cell-mediated immunity. In our case, the patient had myelodysplastic syndrome. However, approximately one third of infections occur in immunocompetent patients. Inhalation of the bacteria into the lungs from contaminated soil is the typical route of infection. Patients may experience symptoms of a nonproductive cough, dyspnea, chest pain, hemoptysis, fever, night sweats, weight loss, and fatigue. Imaging of pulmonary nocardiosis can show focal or multifocal nodular lesions, consolidated infiltrations, or cavitary lesions.3 The central nervous system is the most common extrapulmonary site of infection, and brain abscess formation is not uncommon. Regarding the eye, Nocardia infection can manifest as scleritis, keratitis, or endophthalmitis.4 Nocardia scleritis and keratitis are typically caused by trauma with direct inoculation of bacteria. Nocardia exogenous endophthalmitis has been reported after trauma or cataract surgery.
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CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
Endogenous endophthalmitis typically arises from pulmonary infection. Nocardia endophthalmitis often presents with a single white subretinal lesion with surrounding hemorrhage and retinal thickening with overlying vitritis. Sulfonamides are the antimicrobial treatment of choice, but drug susceptibility testing is important to identify resistant strains.5 In this unique case, the patient was initially suspected to have metastatic disease to the eye from primary lung carcinoma, especially with negative systemic evaluation for infection. We suspect that the underlying myelodysplastic syndrome and immune deficiency increased the risk for Nocardia infection. Therefore, we recommend Nocardia infection to be considered in any patient with atypical lung nodules and panuveitis, particularly in those with immune deficiency.
Acknowledgements: The authors acknowledge Dr. Ralph C. Eagle for providing the pathology photographs.
David R. Lally, * Dinesh K. Sharma, † Carol L. Shields, ‡ Barry C. Malloy, § Sunir J. Garg * *The
Retina Service of Wills Eye Institute, MidAtlantic Retina, Jefferson Medical College; †Jefferson Medical College, ‡Wills Eye Institute, Jefferson Medical College, Philadelphia; and § Eye Consultants of Pennsylvania, PC, Wyomissing, Pa
Correspondence to: Sunir J. Garg, MD: [email protected] REFERENCES 1. Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006;19:259-82. 2. Wallace RJ Jr, Steele LC, Sumter LC, Smith JM. Antimicrobial susceptibility patterns of Nocardia asteroids. Antimicrob Agents Chemother. 1988;32:1776-9. 3. Kanne JP, Yandow DR, Mohammed TH, Meyer CA. CT findings of pulmonary nocardiosis. AJR Am J Roentgenol. 2011;197:W266-72. 4. DeCroos FC, Garg P, Reddy AK, et al. Optimizing diagnosis and management of nocardia keratitis, scleritis, and endophthalmitis: 11 year microbial and clinical overview. Ophthalmology. 2011;118:1193-200. 5. Ambrosioni J, Lew D, Garbino J. Nocardiosis: updated clinical review and experience at a tertiary center. Infection. 2010;38:89-97. Can J Ophthalmol 2014;49:e59–e62 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.02.003
REFERENCES 1. Postel EA, Pulido JS, McNamara JA, Johnson MW. The etiology and treatment of macular detachment associated with optic nerve pits and related anomalies. Trans Am Ophthalmol Soc. 1998;96:73-88, discussion 88-93.
Pulmonary nocardiosis initially manifesting as endogenous endophthalmitis Endogenous endophthalmitis is a rare sequela of pulmonary nocardiosis. We present a case of pulmonary nocardiosis that
2. Zumbro DS, Jampol LM, Folk JC, Olivier MMG, Anderson-Nelson S. Macular schisis and detachment associated with presumed acquired enlarged optic nerve head cups. Am J Ophthalmol. 2007;144:70-4. 3. Sugar HS. An explanation for the acquired macular pathology associated with congenital pits of the optic disc. Am J Ophthalmol. 1964;57:833-5. 4. Spaide RF, Costa DL, Huang SJ. Macular schisis in a patient without an optic disk pit optical coherence tomographic findings. Retina. 2003;23:238-40. 5. Doyle E, Trivedi D, Good P, Scott RA, Kirkby GR. High-resolution optical coherence tomography demonstration of membranes spanning optic disc pits and colobomas. Br J Ophthalmol. 2009;93:360-5. Can J Ophthalmol 2014;49:e56–e59 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.01.003
initially manifested as endogenous endophthalmitis and showed an appearance simulating choroidal metastatic disease. Nocardia infection should be considered in any patient with atypical lung nodules and panuveitis, particularly in those with immune deficiency.
Fig. 1 — External photograph of left eye on presentation demonstrates injected conjunctiva with a clear cornea and an approximately 1-mm hypopyon (upper left). Fundus photograph of the left eye on presentation shows dense vitritis. The optic nerve (arrow) and a white round lesion along the inferior arcade (chevron, upper right) are visible. B-scan ultrasonography of left eye discloses vitreous debris with a deep retinal elevation appearing irregular and with a cleft overlying the normal choroid (lower left). A-scan ultrasound of left eye discloses medium echoes within the lesion (lower right). CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
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Correspondence
Fig. 2 — CT of the chest demonstrates a 16 8-mm solid lesion (arrow) in the medial portion of the left upper lobe (top panels). Another lesion (chevron) in the medial portion of the anterior segment of the right upper lobe measures 12 mm in diameter (bottom panels).
Fig. 3 — Histopathology discloses disorganized retina architecture with multiple retinal microabscesses. Gram stain discloses branching, gram-positive rods. (Left) Hematoxylin and eosin stain. Original magnification 10. (Right) Gram stain. Original magnification 50.
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CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
Correspondence An 80-year-old white male presented with a 1 week history of floaters, decreased vision, and pain in the left eye. He had no ocular history. His medical history was significant for myelodysplastic syndrome with chronic anemia diagnosed 2 years previously. Other medical conditions included cardiovascular disease, hypertension, rosacea, and osteoarthritis. His medications included doxycycline, felodipine, meloxicam, clonazepam, and simvastatin. On review of systems, he noted occasional dyspnea on exertion for 2 weeks. He denied fevers, weight changes, night sweats, or internal artificial devices. He was a nonsmoker and consumed a moderate amount of alcohol weekly. On examination, best corrected visual acuity was 20/30 OD and count fingers in the left eye. Pupils were 3 mm and reactive in each eye without relative afferent pupillary defect. The right eye showed a moderate cataract but was otherwise unremarkable. The left eye demonstrated poor dilation with
moderate conjunctival injection, clear cornea, moderate cataract, and a shallow inferior hypopyon. Fundus examination of the left eye revealed dense vitritis with a round, white mass along the inferior retinal vascular arcade (Fig. 1) that appeared solid on ultrasonography with overlying vitreous debris and history underlying intact choroid. CT of the chest (Fig. 2) disclosed a 16 8-mm spiculated soft-tissue nodule in the left upper lobe adjacent to the aortic arch. A second 12 12-mm nodule was observed within the right upper lobe adjacent to the aortic arch. Three blood cultures, lyme Western blot, fluorescent treponemal antibody (FTA), rapid plasma reagin (RPR), and HIV tests were negative. Transthoracic echocardiogram was normal. At this point, primary lung carcinoma with metastatic disease to the eye versus infectious process was suspected. A diagnostic vitrectomy with lensectomy and retinal photocoagulation was performed. During the operation,
Fig. 4 — CT of the chest 6 months after Figure 1 imaging demonstrates complete resolution of the lesion in the left upper lobe (arrow) and right upper lobe (chevron). Bibasilar atelectasis is also present, which was attributed to hypoventilation secondary to chest trauma. Notably, the patient is more kyphotic compared with Figure 2. CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
e61
Correspondence extensive retinal whitening and hemorrhage were observed along the inferior arcade. The vitreous fluid had negative KOH and Gram stains. Polymerase chain reaction for herpes simplex virus, varicella zoster virus, cytomegalovirus, and toxoplasmosis were negative. Flow cytometry was negative. Routine and fungal cultures were negative for growth at 1 week. Over 1 week, the extent of retinitis increased, and a retinal biopsy was performed and revealed gram-positive branching rods (Fig. 3). The initial vitreous fluid culture grew Nocardia farcinica on the 10th day. The patient was treated with oral sulfamethoxazoletrimethoprim double strength twice per day for 6 weeks. At the 3-month follow-up visit, the patient’s visual acuity was hand motions in the left eye, and the retinal infection resolved. Six months after initial presentation, the patient suffered an unrelated fall and underwent chest CT, which disclosed resolution of the previously documented lung lesions (Fig. 4). The final diagnosis was pulmonary nocardiosis with initial manifestation as endophthalmitis and with complete response to 6 weeks of oral sulfamethoxazole-trimethoprim therapy. Nocardia is a group of more than 50 species of grampositive, aerobic, filamentous, and weakly acid-fast bacteria. The taxonomy is challenging with many revisions over the past few decades.1 The species were originally referred to as Nocardia asteroides, but later found to be a group of bacteria with a heterozygous pattern of antimicrobial drug susceptibility.2 Nocardia is typically an opportunistic infection observed in patients with depressed cell-mediated immunity. In our case, the patient had myelodysplastic syndrome. However, approximately one third of infections occur in immunocompetent patients. Inhalation of the bacteria into the lungs from contaminated soil is the typical route of infection. Patients may experience symptoms of a nonproductive cough, dyspnea, chest pain, hemoptysis, fever, night sweats, weight loss, and fatigue. Imaging of pulmonary nocardiosis can show focal or multifocal nodular lesions, consolidated infiltrations, or cavitary lesions.3 The central nervous system is the most common extrapulmonary site of infection, and brain abscess formation is not uncommon. Regarding the eye, Nocardia infection can manifest as scleritis, keratitis, or endophthalmitis.4 Nocardia scleritis and keratitis are typically caused by trauma with direct inoculation of bacteria. Nocardia exogenous endophthalmitis has been reported after trauma or cataract surgery.
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CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
Endogenous endophthalmitis typically arises from pulmonary infection. Nocardia endophthalmitis often presents with a single white subretinal lesion with surrounding hemorrhage and retinal thickening with overlying vitritis. Sulfonamides are the antimicrobial treatment of choice, but drug susceptibility testing is important to identify resistant strains.5 In this unique case, the patient was initially suspected to have metastatic disease to the eye from primary lung carcinoma, especially with negative systemic evaluation for infection. We suspect that the underlying myelodysplastic syndrome and immune deficiency increased the risk for Nocardia infection. Therefore, we recommend Nocardia infection to be considered in any patient with atypical lung nodules and panuveitis, particularly in those with immune deficiency.
Acknowledgements: The authors acknowledge Dr. Ralph C. Eagle for providing the pathology photographs.
David R. Lally, * Dinesh K. Sharma, † Carol L. Shields, ‡ Barry C. Malloy, § Sunir J. Garg * *The
Retina Service of Wills Eye Institute, MidAtlantic Retina, Jefferson Medical College; †Jefferson Medical College, ‡Wills Eye Institute, Jefferson Medical College, Philadelphia; and § Eye Consultants of Pennsylvania, PC, Wyomissing, Pa
Correspondence to: Sunir J. Garg, MD: [email protected] REFERENCES 1. Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006;19:259-82. 2. Wallace RJ Jr, Steele LC, Sumter LC, Smith JM. Antimicrobial susceptibility patterns of Nocardia asteroids. Antimicrob Agents Chemother. 1988;32:1776-9. 3. Kanne JP, Yandow DR, Mohammed TH, Meyer CA. CT findings of pulmonary nocardiosis. AJR Am J Roentgenol. 2011;197:W266-72. 4. DeCroos FC, Garg P, Reddy AK, et al. Optimizing diagnosis and management of nocardia keratitis, scleritis, and endophthalmitis: 11 year microbial and clinical overview. Ophthalmology. 2011;118:1193-200. 5. Ambrosioni J, Lew D, Garbino J. Nocardiosis: updated clinical review and experience at a tertiary center. Infection. 2010;38:89-97. Can J Ophthalmol 2014;49:e59–e62 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.02.003
