Nocardia keratitis presenting as an anterior chamber ball of exudates and its management

Abstract

A man in late 40s presented with corneal ulcer of the right eye of 1 month duration. He had a central corneal epithelial defect measuring 4.6×4.2 mm with an underlying 3.6×3.5 mm anterior to mid stromal patchy infiltrate and 1.4 mm hypopyon. Gram stain of the colonies on chocolate agar showed presence of confluent thin branching, gram-positive beaded filaments, which were positive after 1% acid fast stain. This confirmed our organism to be Nocardia sp. Topical amikacin was started but continued worsening of the infiltrate and presence of a ball of exudates in the anterior chamber, prompted the use of systemic trimethoprim-sulfamethoxazole. There was a dramatic improvement in the signs and symptoms, with complete resolution of infection over a period of 1 month.

Keywords: Anterior chamber; Drugs: infectious diseases.

Figure 1

(A) Slit-lamp image of right eye showing a central corneal epithelial defect of 4.6×4.2 mm with an underlying 3.6×3.5 mm anterior to mid stromal patchy infiltrate having a hypopyon of 1.4 mm, (B) fluorescein stained image of the same observed under blue filter, (C) Gram’s stain (×100) revealing Gram positive thin beaded filaments and also depicting, (D) acid fast positive nature of the organism.

Figure 2

Clinical deterioration—slit lamp photographs 7 (A), 15 (B) and 21 (C) days after first presentation. Note the small pinhead-like gray-white infiltrates initially appearing as satellites at the edge of the superficial lesion, and subsequently spreading over the affected area while increasing in size and also the increase in retrocorneal exudates eventually forming an anterior chamber (AC) ball.

Figure 3

(A, B, C, D) Slit lamp photographs of resolution of nocardia keratitis after adding oral sulfamethoxazole/trimethoprim.

Figure 4

(A, B) At the final review; right eye showed a nebulo-macular corneal scar involving the visual axis and no anterior chamber activity was noted.