Nocardia arthritidis scleritis: A case report

Abstract

Purpose: This report describes a case and management of a 69-year-old female with infectious scleritis found to be caused by Nocardia arthritidis species.

Observations: Our patient presented with severe constant pain in the left eye (OS) following cataract surgery. She had a pertinent past medical history significant for renal transplantation (on oral tacrolimus, mycophenolate, and prednisone). Slit lamp examination OS (1 month after cataract surgery) demonstrated 3+ injection temporally accompanied by scleral thickening and multiloculated abscesses with purulent drainage from small conjunctival erosions. The abscesses were debrided and sent for gram stain and culture. The patient was treated with repeated subconjunctival injections of antibiotics and an antifungal; topical amphotericin, vancomycin, and amikacin; and oral trimethoprim-sulfamethoxazole (double strength). Two separate gram stains with cultures confirmed the diagnosis and species identification. The patient responded well to repeat subconjunctival injections early on in addition to the prescribed regimen, remaining free of disease at the last follow-up (12 months following presentation).

Conclusions and importance: This unique case demonstrates infectious scleritis caused by an uncommon Nocardia species (N. arthritidis) that was successfully treated with similar strategies used for other reported Nocardia species. As Nocardia scleritis can lead to adverse outcomes if not treated promptly and properly, it should be considered on the differential diagnoses in an immunocompromised patient who presents with acute ocular symptoms after any recent ocular surgery.

Keywords: BCL, bandage contact lens; HIV, Human Immunodeficiency Virus; Infectious scleritis; LASIK, laser-assisted in-situ keratomileusis; Nocardia; Nocardia arthritidis; OD, Right eye; OS, Left eye; Scleritis; TMP/SMX, trimethoprim-sulfamethoxazole.

Fig. 1

Slit lamp photograph at presentation demonstrates left eye conjunctival/scleral injection temporally accompanied by multiloculated abscesses with purulent drainage (1A). Fluorescein demonstrates multiple small conjunctival erosions in the area (1B).

Fig. 2

Slit lamp photograph demonstrating improvement (smaller conjunctival defects/staining, less injection) 3 weeks after debridement, subconjunctival injections, and change in therapy (2A). By 4–5 weeks, there was resolution of the conjunctival defects, less injection, conjunctival scarring, and scleromalacia (2B). At 6 months follow-up, slit lamp photograph demonstrates a white, quiet eye with mild scleromalacia (2C).

Fig. 3

Slit lamp photographs (with and without fluorescein) depict examples of the conjunctival defects with a serpentine border along with mild fibrosis and pseudomembranes, affecting the superior (3A and 3B), nasal (3C and 3D), and inferior (3E and 3F) conjunctiva.