Disseminated Nocardiosis with subretinal abscess in a patient with nephrotic syndrome-a case report

Abstract

BackgroundNocardia infection is uncommon in clinical practice, with most cases occuring as the result of opportunistic infection in immunocompromsed patients. Here, we report a case of disseminated nocardiosis with subretinal abscess in a patient with nephrotic syndrome, and whom is receiving immunosuppressive therapy.Case presentationA 58-year-old male presented with decreased vision in his left eye, without redness or floaters, which had persisted for three days. The patient had previously been diagnosed with membranous nephropathy, and as such, had received systemic corticosteroid therapy for four months. Further, the patient had developed pneumonia three weeks prior to this presentation. The ocular lesion appeared as a creamy-white subretinal abscess, with overlying retinal hemorrhages. Subsequent administration of three intravitreal injections of vancomycin and ceftazidime ultimately led to eradication of the intraocular infection, however, two months later, the patient developed a brain abcess. Pathogens isolated from the blood were subsequently identified as Nocardia. The patient was successfully treated via systemic administration of imipenem and trimethoprim-sulfamethoxazole.ConclusionsClinicians should be aware of the possibility of Nocardia infections within all immunocompromised patients, as well as the tendency of this infection to disseminate--particularly in the brain. The early detection of Nocardia infections and prolonged treatment of the proper antibiotics may significantly improve the prognosis of this life-threatening infection.

Nocardia Infection in Nephrotic Syndrome Patients: Three Case Studies and A Systematic Literature Review

“…Ten articles described 24 cases that had sufficient individual patient data. Table S2 summarizes these publications ( Hwang et al., 2004 ; Sirijatuphat et al., 2013 ; Zhou et al., 2014 ; Chen et al., 2016 ; Zhu et al., 2017 ; Xu et al., 2018 ; Guo et al., 2020 ; Han et al., 2020 ; Sah et al., 2020 ; Yang et al., 2020 ). A total of 27 cases of nocardiosis with NS were assessed, including the three cases of nocardiosis in our hospital.…”

The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective

“…This agent does achieve therapeutic levels in the vitreous following oral administration [1]. Oral administration of trimethoprim-sulfamethoxazole as adjunctive therapy has been reported in the treatment of endogenous endophthalmitis with subretinal abscess due to Nocardia [23,24], MRSA [25], and other organisms. Risks associated with trimethoprim-sulfamethoxazole include nausea, vomiting, peripheral neuritis, Stevens-Johnson syndrome, and toxic epidermal necrolysis.…”

Systemic nocardiosis presenting with subretinal abscess in patient with Hodgkin's lymphoma

“…Solid Descemet's membrane detachment without haemorrhage has been reported in 1.6%-3.7% of cases. 1,2 It is probably induced by the intraoperative injection of viscoelastic through Schlemm's canal, thereby rupturing the Trabeculo-Descemet's window. 3 Subsequent intracorneal haematoma is however deemed rare with a postulated risk factor being postoperative hypotony enabling blood reflux into Schlemm's canal ().…”

“…4 Endogenous Nocardia endophthalmitis is exceedingly rare with less than 40 cases reported. 1,5 When Nocardia disseminates to the eye, it causes choroidal or subretinal abscess formation which has been described in all previously reported cases of endogenous Nocardia endophthalmitis. 3 As it forms within intraretinal or subretinal compartments, vitreous aspirations tend to be inadequate for diagnosis as seen in our case.…”

“…Infection typically results in acute or chronic suppurative necrosis and abscess formation, which due to intrinsic properties and virulence factors, are pathological hallmarks of Nocardiosis. [1][2][3] Nocardia typically presents with pneumonia, lung abscesses or cavitating lung lesions which may then (in 20%-50%) cause disseminated infection in any distant tissue. 2 The brain is most commonly involved which is seen in 15% whilst the choroid may be involved in 3%-5%.…”