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Journal of Clinical Microbiology, April 1998, p. 1154-1156, Vol. 36, No. 4
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
Corneal Ulcer Caused by Nocardia
asteroides in a Patient with Leprosy
Uma M.
Tendolkar,1,*
Ami
Varaiya,1
A. S.
Ahuja,2
S. A.
Motwane,2 and
A.
S.
Gogate1
Department of
Microbiology1 and
Department of
Ophthalmology,2 Lokmanya Tilak Municipal
Medical College and Hospital, Sion, Mumbai 400 022, India
Received 2 September 1997/Returned for modification 7 November
1997/Accepted 23 December 1997
 |
ABSTRACT |
Nocardia asteroides is a rare cause of keratitis
usually associated with trauma. We report a case of corneal ulceration
caused by N. asteroides in a patient with leprosy. This is
the first case report of nocardial keratitis from Southeast Asia. The
diminished corneal sensation in a patient with leprosy could be a
predisposing factor for development or exacerbation of corneal
ulceration.
| |
TEXT |
Nocardia asteroides is a
rare cause of keratitis usually associated with trauma (3).
All of the cases of nocardial keratitis reported so far had been in
Western countries (3, 7, 8, 10). Cases of bilateral
conjunctivitis and of endophthalmitis due to N. asteroides
have been reported from India (6) and Japan (9),
respectively. This case is the 12th report of N. asteroides
as a causative agent of corneal ulceration and the first report from
Southeast Asia. Of all the cases reported so far, only one case
involved a questionable diagnosis, of scarlet fever, as a condition
predisposing the patient to the development of corneal ulceration. In
the present case, there was no history of injury. A predisposing
condition which may have led to the development of ulceration was
leprosy.
Case report.
A 45-year-old housewife presented with diminished
vision in the left eye of 5 days' duration. She also experienced pain,
redness, and watering in the left eye. On examination, the patient had lagophthalmos. There was perception and propagation of light in all
four quadrants. The conjunctiva was congested. Corneal sensation was
totally absent in the left eye and was decreased in the right eye.
Sensation was determined by the sterile cotton wisp test. The corneal
ulcer in the left eye was central and 4 mm in diameter, with a
surrounding infiltrate and a few satellite lesions that were
inferotemporal and inferomedial. The anterior chamber, which showed
intense iritis, exhibited hypopyon in one-fifth of the area. Tension
was digitally high. The lacrimal sac was patent. An examination of the
right eye showed a peripheral corneal opacity in the inferior quadrant
with evidence of pannus, suggestive of an old trachoma and the presence
of an immature cataract.
The patient gave no history of trauma or foreign-body implantation
preceding the development of corneal ulceration in the left eye. A
gynecological, medical, otolaryngological, and dental examination was
done to rule out a septic focus. On dermatological examination, the
patient was diagnosed with borderline tuberculoid leprosy, with an
anesthetic patch on the left forearm with a thickened left ulnar nerve.
Split-skin smears did not show any acid-fast bacilli. Human
immunodeficiency virus and Venereal Disease Research Laboratory tests
were negative, and the results of other hematological and biochemical
investigations were within normal limits.
Corneal scrapings collected from the left eye were stained by Gram
stain and also observed in a 10% KOH mount to rule out
fungi. The
gram-stained smear revealed numerous epithelial cells,
few pus cells,
and gram-positive thin branching hyphae, some of
which were broken into
bacillary and coccoid forms (Fig.
1). The
smear was suggestive of an actinomycete. Modified acid-fast staining
using 1% sulfuric acid as the decolorizer revealed acid-fast branching
hyphae.
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FIG. 1.
Gram-stained smear of corneal scrapings showing
polymorphonuclear cells, gram-positive branching hyphae, and bacillary
and coccoid forms of N. asteroides. Magnification,
×1,000.
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|
Culture was performed on Sabouraud dextrose agar, Lowenstein-Jensen
medium, and modified Thayer-Martin medium. After an incubation
of 7 days, light-orange-colored, rough, wrinkled, dull colonies
appeared on
all three of the media. Detailed biochemical and physiological
testing
(
11) revealed the growth to be
N. asteroides.
Based on these findings, a diagnosis of
N. asteroides
keratitis was made. The patient was treated systemically with
gentamicin
(60 mg) by injection three times a day, oral ampicillin (250 mg)
four times a day, oral trimethoprim-sulfamethoxazole (160 mg-800
mg) twice daily, and oral acetazolamide (250 mg) twice daily.
For
treatment of leprosy, the use of oral rifampin (600 mg) for
1 month and
oral diaminodiphenyl sulfone (100 mg) for 6 months
was advised. Topical
treatment of the left eye consisted of ciprofloxacin
eye drops (0.03%)
once hourly, penicillin eye drops (1:10,000)
once hourly,
tobramycin-fortified eye drops (15 mg%) once hourly,
and atropine
(1%) ointment twice daily. With this treatment, marked
improvement was
seen in the affected eye after 10 to 12 days.
After 2 weeks of
hospitalization, the patient was better and the
eye was quiet. The
infiltrate was reduced in size, with a hypopyon
streak.
The patient was discharged but was asked to visit the outpatient
department for follow-up. Thereafter, however, she was lost
to
follow-up.
Discussion.
Nocardia species are associated with
environmental materials, including soil. They commonly cause mycetomas
and pulmonary infections but rarely are pathogens of the eye
(3). In all of the previously reported cases (Table
1), a diagnosis was based on smear and/or
culture positivity. Although clinical photographs and photographs of
cultures were provided, primary-smear photographs were lacking in these
reports. A primary smear made directly from a clinical lesion offers a
rapid diagnosis, which is critical for institution of appropriate
therapy for serious infections like corneal ulcers. The classical
appearance of the organisms in the smears (Fig. 1), fortified by
culture results, helped us to obtain an unequivocal diagnosis in this
case.
Corneal ulcers are predominantly seen in males (Table
1), which may be
a result of occupational exposure. This is evident
in the seven cases
of
Nocardia keratitis reviewed by Hirst et
al. in 1979 (
7). A questionable diagnosis of scarlet fever
as a
predisposing cause has been reported by Benedict and Iverson
(
1). Overall, in eight cases, patients had a definite
history
of injury to the eye.
In both the lepromatous and tuberculoid types of leprosy, some degree
of corneal anesthesia or hypesthesia may occur. In the
lepromatous
type, ocular complications are common, taking the
form of lepromatous
nodules and keratitis. In the tuberculoid
type, on the other hand,
exposure keratoconjunctivitis associated
with paralytic lagophthalmos
may occur (
4).
In our case, there was no obvious history of injury. The ulcer
apparently developed spontaneously in an eye affected by lagophthalmos
resulting from a borderline tuberculoid type of leprosy. Absence
of
corneal sensation could be the reason that the patient did
not feel any
pain even if there was a trauma.
There is a possibility that
N. asteroides was an opportunist
in the dry eye resulting from lagophthalmos or that the patient
was
unaware of any trauma due to the absence of corneal sensation.
Due to
decreased corneal sensation and the resultant decreased
perception of
pain, the patient was treated late in the course
of the disease, which
is evident from the fact that a hypopyon
had already developed and the
eye was less irritated than is generally
seen in infections with other
bacteria, such as pneumococcus,
Pseudomonas species, etc.
There is also a possibility that the present case is similar to a
previous case report (
10) and that the patient's diagnosis
of leprosy may be irrelevant. In the case reported by Meurs and
van
Bijsterveld (
10), there was no history of trauma to the
eye,
nor was there any predisposing condition which could have
led to an eye
infection.
Even in the absence of history of injury to the eye, a patient with
leprosy is likely to develop an opportunistic infection
like that with
N. asteroides.
| |
ACKNOWLEDGMENTS |
We thank our dean, R. G. Shirahatti, for allowing us to
publish this report of a case encountered during routine hospital care.
We also acknowledge the technical assistance of Jagdish Sharma.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Dept. of
Microbiology, Lokmanya Tilak Municipal Medical College and Hospital,
Sion, Mumbai 400 022, India. Phone: (022) 4076381, ext. 347. Fax: 91 22 4455929. E-mail: gogate{at}poboxes.com.
| |
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Journal of Clinical Microbiology, April 1998, p. 1154-1156, Vol. 36, No. 4
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
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