Author: Ricardo Machado Soares (Portugal)
Co-authors: Joana Da Silva Fernandes, Catarina Cunha Ferreira, Sofia Fonseca, Miguel Bilhoto
Purpose
To report a case of a patient that was diagnosed with Systemic Nocardiosis after subretinal fluid aspiration bacteria culture test.
Setting/Venue
Department of Ophthalmology - Centro Hospitalar de Vila Nova de Gaia e Espinho - Portugal
Methods
Case report based on clinical history, ophthalmologic evaluation (visual acuity, slit-lamp examination, and indirect ophthalmoscopy), and findings on ancillary exams (retinography, optical coherence tomography, chest computerized tomography, and neuro-imaging) and pars plana vitrectomy surgery.
Results
A 72-year-old female, with a history of autoimmune hepatitis (controlled with azathioprine and prednisolone) and recent stroke, was admitted to the emergency ward with a 3-week history of altered state of consciousness and dysphasia. After a careful examination and complementary diagnosis tests, a presumed diagnosis of Pulmonary Tuberculosis (based on imagiologic findings) was made, and she was hospitalized. On the third day of hospitalization, she also complained of diminished visual acuity (VA) in the left eye (OS). On exam, VA was was 20/30 and “counting fingers” on her right and OS, respectively. On slit-lamp examination, conjunctival hyperemia with ciliary injection, cells and flare in the anterior chamber was observed. Fundoscopy revealed a white submacular abscess in the temporal inferior macula and an exudative retinal detachment. Due to progressive clinical deterioration, drug refractoriety, and absence of significant findings on ancillary exams, a vitreous biopsy, and subretinal fluid aspiration were performed. Neuroimaging was repeated, revealing 2 new brain lesions. Bacteria culture test of subretinal fluid was positive for Nocardia cyriacigeorgica. Directed therapy with trimethoprim/sulfamethoxazole and linezolid was immediately initiated with favorable response and the patient was eventually discharged from the intensive care unit.
Conlusions
Due to its rarity, Nocardiosis is not a commonly considered diagnosis. However, in the case of brain, lung, and eye abscesses and immunosuppression, a high index of suspicion is needed.
Financial Disclosure
None
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