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Case Reports
. 2018 Jan 10:10:1-5.
doi: 10.1016/j.ajoc.2018.01.018. eCollection 2018 Jun.

Nocardial scleritis: A case report and a suggested algorithm for disease management based on a literature review

Laura Pires da Cunha  1 , Verena Juncal  1 , Cecília Godoy Carvalhaes  2 , Sylvia Cardoso Leão  3 , Erica Chimara  4 , Denise Freitas  1
Affiliations
Case Reports

Nocardial scleritis: A case report and a suggested algorithm for disease management based on a literature review

Laura Pires da Cunha et al. Am J Ophthalmol Case Rep. .

Abstract

Purpose: To report a case of nocardial scleritis and to propose a logical treatment algorithm based on a literature review.

Observations: It is important to suspect a nocardial infection when evaluating anterior unilateral scleritis accompanied by multiple purulent or necrotic abscesses, especially in male patients with a history of chronic ocular pain and redness, trauma inflicted by organic materials, or recent ophthalmic surgery. A microbiological investigation is essential. In positive cases, a direct smear reveals weakly acid-fast organisms or Gram-positive, thin, beading and branching filaments. Also, the organism (usually) grows on blood agar and Lowenstein-Jensen plates. An infection can generally be fully resolved by debridement of necrotic areas and application of topical amikacin drops accompanied by systemic sulfamethoxazole-trimethoprim.

Conclusions and significance: Together with the case report described, we review data on a total of 43 eyes with nocardial scleritis. Our proposed algorithm may afford a useful understanding of this sight-threatening disease, facilitating easier and faster diagnosis and management.

Keywords: Infection; Microbiology; Necrotizing; Nocardia; Scleral disease.

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Figures

Fig. 1
Fig. 1
Anterior biomicroscopy of a right eye with a Nocardia pseudobrasiliensis infection. First appointment: A. In the primary position, the eye exhibits diffuse hyperemia of the conjunctiva and cornea, with Descemet folds. B. The eye positioned to show the multifocal abscesses and the area of necrosis. Last appointment: C. In the primary position, the eye exhibits resolution of the infection but residual scleral thinning. D. In the up-gaze position, the abscesses and the necrosis are seen to have resolved.
Fig. 2
Fig. 2
Microbiology of Nocardia pseudobrasiliensis. A. A photomicrograph (Ziehl-Neelsen staining, 1000×) showing filamentous branching rods after 3 days of incubation. B. A photograph of a Lowenstein–Jensen culture plate showing light-orange colonies. C. Photograph of a blood agar plate exhibiting colony growth. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
Fig. 3
Fig. 3
The Nocardial Scleritis Clinical Algorithm: from clinical presentation to diagnosis and management.
See this image and copyright information in PMC

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