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

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.

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

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

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