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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 211-213

Nocardia keratitis: A case report from tertiary care hospital of Punjab, India


1 Department of Microbiology, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India
2 Department of Ophthalmology, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India

Date of Web Publication17-Aug-2017

Correspondence Address:
Sheevani Sheemar
144, Gurjeet Nagar, Garha Road, Jalandhar - 144 022, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_79_16

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  Abstract 


Keratitis due to Nocardia species is a rare clinical presentation. We present a case report of Keratitis caused by Nocardia asteroides in an immunocompetent 23-year-old male without any history of trauma or previous ocular intervention. Clinical picture of the patient indicated fungal pathology but good collaboration between the clinical and diagnostic departments helped in timely diagnosis and appropriate management of the patient.

Keywords: Immunocompetent, Keratitis, Nocardia


How to cite this article:
Sheemar S, Chand K, Kaur J, Moudgill T. Nocardia keratitis: A case report from tertiary care hospital of Punjab, India. J Med Soc 2017;31:211-3

How to cite this URL:
Sheemar S, Chand K, Kaur J, Moudgill T. Nocardia keratitis: A case report from tertiary care hospital of Punjab, India. J Med Soc [serial online] 2017 [cited 2019 Jul 23];31:211-3. Available from: http://www.jmedsoc.org/text.asp?2017/31/3/211/211105




  Introduction Top


Nocardia species are branching filamentous Gram-positive bacteria. These are ubiquitous saprophytes present in soil, water, and organic matter. Nocardia species are well recognized cause of pulmonary infections, mycetoma, and disseminated nocardiosis. Ocular nocardiosis is an uncommon entity. We present the first case (to the best of our knowledge) of Nocardia keratitis from Punjab, Northern India.


  Case Report Top


A 23-year-old man presented with redness and decreased visual acuity in his right eye for the past twenty to 30 days in outdoor patient Department of Ophthalmology. He had no history of trauma or any foreign body in the eye. Patient gave the history of previous consultation and medication from some other hospital. As per his history, there was no respite in the symptoms despite medication for about 2 weeks. On visual examination, vision in his left eye was 6/6 with no ocular abnormality and in the right eye it was 6/12. There was conjunctival congestion and mild edema/swelling in the right eye. There was white infiltrate in the inferonasal quadrant of the cornea. In the slit beam, the infiltrate was superficial and measured 3.8 mm × 3.0 mm [Figure 1]. As for the past history, there was no history of any ocular surgery or prolonged treatment. On the basis of clinical picture, patient was put on topical antifungal agent.
Figure 1: Slit lamp examination of eye showing Nocardia Keratitis

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Corneal scrapings were sent for fungal KOH mount, Gram-staining, bacterial culture and fungal culture to the Microbiology Department. Corneal scrapings for fungal KOH mount were found to be negative. Gram-staining revealed inflammatory cells and a single bunch of beaded, branched thin long filaments of Gram-positive nature suggesting Nocardia species. Presumptive diagnosis was made by performing modified Ziehl Neelsen staining with one percent sulfuric acid. Smear was positive for acid-fast thin filaments [Figure 2]. Ophthalmology department was informed. Antifungal treatment was stopped and patient was put on topical amikacin while culture and susceptibility report was awaited. Bacterial culture for was performed on blood agar and chocolate agar and incubation was performed in the presence of 5% carbon dioxide. Sabouraud's dextrose agar (SDA) with or without antibiotics were inoculated for fungal culture and incubated in BOD incubator. Positive growth of dry rough pale to white colonies was obtained along the “C” inoculum site on both blood and chocolate agar plates after 72 h of incubation at 35°C–37°C. SDA without antibiotics showed the growth of dry whitish colonies after 4 days of incubation at 27°C–30°C. SDA with antibiotics was sterile even after 7 days of incubation. Staining done from colonies from blood agar and SDA showed the similar pattern of fragmented Gram-positive filaments which were found to be acid-fast on modified acid-fast staining. The isolate was catalase and urease positive. The strain reduced the nitrates to nitrites and did not hydrolyze xanthine, hypoxanthine, trypsin, and starch. On the basis of the staining characters, culture characters, and biochemical reactions isolate was identified as Nocardia asteroides. Isolate was tested for antimicrobial susceptibility with discs of amikacin (30 mcg), ciprofloxacin (5 mcg), vancomycin (5 mcg), chloramphenicol (30 mcg), cefazolin (30 mcg), ofloxacin (5 mcg), erythromycin (15 mcg), azithromycin (15 mcg), and co-trimoxazole (25 mcg; 1.25/23.75 mcg) using Kirby Bauer disc diffusion method. Media used for performing susceptibility testing was brain heart infusion agar. The strain was susceptible to all the antimicrobial agents except for ofloxacin, ciprofloxacin, and erythromycin. Patient came just twice for the follow up in Ophthalmology outpatient department and on examination, the signs of marked improvement were observed but afterwards follow up was lost.
Figure 2: Modified acid-fast stained (with 1% sulfuric acid) smear under oil immersion lens showing thin entangled acid fast long filaments

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  Discussion Top


Nocardia is a genus of aerobic actinomycetes responsible for localized or disseminated infections in humans as well as animals. It was first isolated from infected cattle in 1888 by Edmond Nocard while in 1890, first human case was reported by Eppinger.[1] Although Nocardia species are environmental saprophytes sporadic clinical cases of ocular nocardiosis have been reported.[2]

Nocardia species are Gram-positive branching filaments with beaded appearance. The chemical composition of their cell wall makes them acid fast and resist decolourization with 1% sulfuric acid. Nocardia grows well on most of the nonselective media. They usually grow within 3–5 days of aerobic incubation. Colonies obtained are either buff colored or chalky white cerebriform in appearance. Molecular methods are available and provide rapid and accurate diagnosis but cost factor and resource limitation is the major hindrance in common use of molecular methods. Conventional microbiological techniques involving battery of biochemical tests for species identification is cost effective and sensitive enough to be used in the routine laboratories.

Pulmonary nocardiosis is the most common manifestation of the bacteria. Nocardia keratitis is not a frequent presentation in clinical practice. Its clinical picture usually mimics fungal infection. Only a few case reports of Nocardia keratitis have been documented. Most of these reports are from Southern part of the country.[3],[4] This is first case from this region of Northern India to the best of our knowledge. Often the triggering factor has been ocular trauma (25%–80%) or foreign body. In our case, keratitis was of obscure origin and there was no history of immunocompromisation. It has been stated in one of the studies that Nocardia species can cause keratitis even in healthy individuals.[5] Our patient belonged to rural background. Other authors have also reported high incidence of Nocardia keratitis in rural population.[5],[6]

The most common species for Nocardia keratitis had been N. asteroides followed by Nippostrongylus brasiliensis and Nocardia otitidiscaviarum.[3] We identified the isolate as N. asteroides on the basis of biochemical reactions. Isolate in this case was susceptible to most of the antibiotics including amikacin which was prescribed to the patient as topical antibiotic. The strain was resistant to ciprofloxacin, ofloxacin, and erythromycin. Variation in susceptibility has been the noticed from the rest of the case reports, this variation may be due to difference in the geographical distribution of the cases. Delay in diagnosis can result in problems regarding the management of the patient as was seen in our case where patient had received prior treatment from private practitioner without getting any laboratory investigation done. A good liaison between the clinician and Microbiologist can help in early detection. We suggest that before starting the empirical therapy in cases of keratitis, corneal scrapings should be sent to laboratory for timely and accurate diagnosis and appropriate management of the cases.

Acknowledgment

My sincere thanks to Mr. Neeraj, Technician Microbiology for providing technical assistance and procuring relevant information about patient and helping in investigating the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eppinger H. Ueber eine neue pathogene cladothrix und eine durch sie hervogerufene pseudotuberculosis. Wien Klin Wochenschr. 1890;287-88.  Back to cited text no. 1
    
2.
Upadhyay MP, Karmacharya PC, Koirala S, Tuladhar NR, Bryan LE, Smolin G, et al. Epidemiologic characteristics, predisposing factors, and etiologic diagnosis of corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.  Back to cited text no. 2
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3.
Sridhar MS, Gopinathan U, Garg P, Sharma S, Rao GN. Ocular Nocardia infections with special emphasis on the cornea. Surv Ophthalmol 2001;45:361-78.  Back to cited text no. 3
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4.
Lalitha P, Tiwari M, Prajna NV, Gilpin C, Prakash K, Srinivasan M. Nocardia keratitis: Species, drug sensitivities, and clinical correlation. Cornea 2007;26:255-9.  Back to cited text no. 4
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5.
Agarwal PK, Roy P, Das A, Banerjee A, Maity PK, Banerjee AR. Efficacy of topical and systemic itraconazole as a broad-spectrum antifungal agent in mycotic corneal ulcer. A preliminary study. Indian J Ophthalmol 2001;49:173-6.  Back to cited text no. 5
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6.
Bharathi MJ, Ramakrishnan R, Vasu S, Meenakshi, Chirayath A, Palaniappan R. Nocardia asteroides keratitis in south India. Indian J Med Microbiol 2003;21:31-6.  Back to cited text no. 6
[PUBMED]  [Full text]  


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