Case Study: December 2007

A 55 year old man, presents with a reduction in vision. Fundoscopy shows a unilateral posterior pole choroidal mass, with serous retinal detachment and a vitritis. A vitreous sample shows some lymphocytes, macrophages and occasional glial cells, without infective agent on culture. No malignancy is identified. The choroidal mass increases in size, necessitating a trans-vitreal aspirate of the mass. The ocular coats are intact.

Figure 1-H and E of the aspirate showing an acute inflammatory exudate.

Figure 2-Silver stain preparation.

The agent in figure 2 shows branching and is weakly gram positive and acid fast.

Questions

1. What is the agent in Figure 2?

2. What is the diagnosis?

3. Which points may it be important to raise with the ophthalmologists about the patient?

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Answers

1. This is Nocardia (not otherwise specified). The feature that distinguishes it from Actinomyces is the acid fast property.

2. Nocardia choroidal abscess.

3. Ask whether the patient is immuno-compromised. In this case, the patient was immuno-competent.

References

Ishibashi Y, Watanabe R, Hommura S et al. Endogenous Nocardia asteroides endophthalmitis in a patient with systemic lupus erythematosis. Am J Ophthalmol 2003; 135: 915-917.

Ng EW, Zimmer-Galler IE, Green WR. Endogenous Nocardia asteroides endophthalmitis. Arch Ophthalmol 2002; 120:210-213

Meyer SL, Font RL, Shaver RP. Intraocualr nocardiosis; report of 3 cases. Arch Ophthalmol 1970; 86: 666-669.