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IMAGES Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 844-845
Eyelid nocardiosis: An unusual presentation


1 Ocular Pathology Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi -110 029, India
2 Oculoplastic & Ocular Oncology Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi -110 029, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Kashyap S, Meel R, Pushker N. Eyelid nocardiosis: An unusual presentation. Indian J Pathol Microbiol 2010;53:844-5

How to cite this URL:
Kashyap S, Meel R, Pushker N. Eyelid nocardiosis: An unusual presentation. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 14];53:844-5. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/844/72079


A 42-year-old man presented with a slow growing mass of five months duration, adjacent to left eye. The mass had become painful since three days before presentation. There was no history of trauma or any other systemic illness. On examination, there was a firm, mildly tender mass, measuring 3 × 2.5 cm superolateral to left eye. Overlying skin was normal. Visual acuity and movements of the eye were normal. The draining lymph nodes were not enlarged. Computerized tomography (CT) scan of orbit was suggestive of an inflammatory mass lesion in the left preseptal region [Figure 1]. A differential diagnosis of granulomatous lesion or pseudotumor was kept. Systemic workup including chest X-ray, complete blood counts, blood sugar and Mantoux test were normal. An empirical treatment with oral steroids for two weeks did not relieve the patient's symptoms. An excision biopsy of the mass was done.
Figure 1: CT scan orbit (coronal cut) showing a well-defined mass lesion in the preseptal area on the left side

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On gross pathological examination, the excised mass was grey white in colour and firm in consistency. Microscopic examination revealed multiple abscesses within the mass. These were surrounded by foreign body giant cells and dense fibrosis. Multiple basophilic bacterial colonies were seen in the center of the abscesses with surrounding filamentous structures [Figure 2]. These colonies were gram positive and stained strongly with Gomori's methenamine silver stain and weakly with acid-fast stain. A diagnosis of nocardial infection was made and patient started on oral trimethoprim-sulfamethoxazole combination. The patient was asymptomatic at 6 months from completion of treatment.
Figure 2: Microphotographs showing (a) A microabscess surrounded by foreign body giant cells and dense fibrosis, with basophilic bacterial colonies (arrow) in center (H and E, magnification ×400); (b) Basophilic bacterial colonies surrounded with filamentous structures (Hoeppli-Splendore reaction) (H and E ×200); (c) and (d) Periodic acid- Schiff stain positive and mildly acid fast bacterial colonies (PAS stain, ×100; Kinyoun's acid fast stain, ×200)

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Nocardia belong to the bacterial order Actinomycetales. They are aerobic, gram positive, acid fast, thin branching, filamentous bacteria that fragment into irregularly shaped rods and cocci. [1] They are present in soil, mud, dust and decaying vegetation. Amongst immunocompromised patients, they primarily affect lungs and may cause disseminated infection. In immunocompetent patients, infection usually occurs via transcutaneous inoculation and primarily affects skin and the subcutaneous tissue. Cutaneous infection may manifest as cellulitis/abscess, lymphocutaneous syndrome, mycetoma and secondary cutaneous involvement with disseminated disease. [2]

Nocardial infection of the eye may manifest as keratitis, scleritis, conjunctivitis and endophthalmitis. [1] Nocardial infections of ocular adnexa that have been reported in literature include dacryoadenitis, canaliculitis and eyelid infections. [3],[4],[5]

Only two cases of eyelid nocardiosis have been reported previously. Both were purely preseptal. One case presented with fluctuant abscesses involving the eyelid with erythema and edema of the entire ocular adnexa. Small skin drainage sites were discovered on close inspection. Skin incision on abscess site released purulent material that grew Nocardia brasiliensis. [3]

The other case presented as an erythematous plaque with central induration and serous crusting in the preseptal area. Swab cultures from the eyelid grew Nocardia brasiliensis. [4] Both these cases had history of preceding trauma and/or wound contamination that explained transcutaneous inoculation. Also, both these cases had significant enlargement of the draining lymph nodes.

In the current case, there was no history of trauma and/or wound contamination. The infection presented as a chronic inflammatory mass in upper eyelid. The draining lymph nodes were normal. No sinuses were found on the overlying skin. The mass was excised completely. There was no drainage of any purulent material perioperatively. Diagnosis was made on histopathological examination. These features make this case of eyelid nocardiosis unusual.

To conclude, nocardial infection of the eyelid may present as an inflammatory mass and must be kept in the differential diagnosis of an eyelid/orbital inflammatory mass lesion.

 
   References Top

1.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. 1
[PUBMED]  [FULLTEXT]  
2.Corti ME, Fioti MF. Nocardiosis: A review. Int J Infect Dis 2003;7:243-50.  Back to cited text no. 2
[PUBMED]    
3.Hunter LR, Krinsky AH, Fleener CH. Preseptal Cellulitis caused by nocardia brasiliensis. Am J Ophthalmol 1992;114:373-4.  Back to cited text no. 3
[PUBMED]    
4.Brannan PA, Kersten RC, Hudak DT, Anderson HK, Kulwin DR. Primary nocardia brasiliensis of the eyelid. Am J Ophthalmol 2004;138:498-99.  Back to cited text no. 4
    
5.Bharathi MJ, Ramakrishnan R, Meenakshi R, Vasu S. Nocardia asteroides canaliculitis: A case report of uncommon aetiology. Indian J Med Microbiol 2004;22:123-5.  Back to cited text no. 5
[PUBMED]  Medknow Journal  

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Correspondence Address:
Seema Kashyap
Ocular Pathology Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72079

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