NOCARDIA CYRIACIGEORGICA KERATITIS: A CASE REPORT

To describe a case of a patient with an extensive corneal ulcer caused by Nocardia cyriacigeorgica.

Ophthalmology Department, São João University Hospital, Porto, Portugal.

We report the case of a 50 year-old male patient presenting to the emergency department of our center with decreased vision, redness, pain and watering in the left eye for the past 3 weeks. There was history of two small central epithelial defects in left eye, as a result of trauma with a stone, treated 4 weeks earlier. Best corrected visual acuity in left eye was counting fingers. On examination an extensive central corneal ulcer (7x6 mm) with well-defined margins, endothelial plaque, deep stromal infiltrate and melting was present. There was evidence of 3+ anterior chamber reaction and 1mm hypopyon. Corneal scrapings were performed for smears and cultures which identified the presence of Nocardia cyriacigeorgica. The patient was treated with hourly topical fortified amikacin and hourly topical and intravenous (15 mg/kg/day) trimethoprim-sulfamethoxazole and admitted to Infectious Diseases Department where systemic involvement was ruled out. Corneal ulcer showed improvement with treatment, however 3 weeks after first observation significant corneal scarring was present and the patient was proposed for therapeutic corneal penetrating keratoplasty.

Nocardia keratitis is a rare entity, frequently misdiagnosed due to its atypical clinical presentation. Suspicion should be raised in patients with long-standing corneal ulcers not responsive to topical conventional treatment and with prior eye trauma with stones, vegetable matter and metallic foreign bodies. Topical amikacin is the mainstay of treatment. Nocardia keratitis diagnosis is challenging, thus, knowledge of its clinical presentation and management holds the key for a good outcome.