Reactions 1680, p280 - 2 Dec 2017 Nocardia keratitis is trauma (especially with vegetative matter), followed by surgery, corticosteroid, and contact lens use" "Prednisolone acetate 1% 4 times daily was then added to his drug regimen. This was stopped 1 week later because Worsening of multidrug resistant Nocardia of slight worsening found on his examination." asteroides complex and worsening of Nocardia keratitis: case report Shah P, et al. Therapeutic Femtosecond Laser-Assisted Lamellar Keratectomy for Multidrug-Resistant Nocardia Keratitis. Cornea 36: 1429-1431, No. 11, Nov 2017. A 30-year-old man developed worsening of multidrug Available from: URL: http://doi.org/10.1097/ICO.0000000000001318 - resistant Nocardia asteroides complex and worsening of USA 803284244 Nocardia keratitis during treatment with prednisolone acetate [dose androute not stated]. The man, who was using contact lens, presented to the emergency department a history of red and painful left eye for nine days. He had maintained a poor contact lens hygiene including sleeping while wearing contact lenses and rinsing the lenses under tap water. He was working in property preservation and had a regular contact with plant matter, but did not have any recent trauma. Examination revealed a best- corrected visual acuity of 20/20 in the right eye and 20/50 in the left eye. Slit-lamp examination revealed diffuse ciliary flush in the left eye and a 1 mm anterior stromal nasal infiltrate. He was diagnosed with infectious keratitis initially and was administered vancomycin and tobramycin. Corneal scrapings for bacterial, fungal and acanthamoeba cultures were obtained. He showed minimal improvement six days later. The results of cultures were negative for microbial growth. His drug regimen was expanded to include 1% prednisolone acetate four times daily. However, on examination one week later, he was found to have a slight worsening of his symptoms. Hence, prednisolone acetate was discontinued one week after initiation. The man was then started on acyclovir due to negative microbial cultures for possible herpes simplex viral keratitis. A repeat culture was again negative for microbial growth. Vancomycin and tobramycin were stopped after two weeks due to lack of improvement, and he was started on trimethoprim/polymixin B [polymyxin B/trimethoprim] for one week. The results of third corneal scraping one week later were again negative. He was then tried on ciprofloxacin. All topical therapies were discontinued following several unchanged examinations and a deep corneal scraping was performed after two days. Nocardia asteroides complex grew in the final culture. He was then administered amikacin 37 days after the initial presentation. However, his clinical condition significantly deteriorated one week later, and new multifocal nasal infiltrates were noted. At this point antibiotic sensitivity results were pending. Then, he was re-administered trimethoprim/polymixin B with minimal improvement. His treatment with amikacin was discontinued and gatifloxacin was added to trimethoprim/polymixin B therapy, but his condition further worsened with central progression of the infiltrate and decline in best-corrected vision to 20/200. The rd focal infiltrate was localised to the anterior 1/3 of the stroma via anterior segment optical coherence tomography. Due to the rapid clinical decline, therapeutic femtosecond laser- assisted lamellar keratectomy was performed under proxymetacaine [proparacaine hydrochloride]. The specimen was then sent for microbial and histopathological analysis. The slit-lamp examination and anterior segment optical coherence tomography showed that the residual stromal bed was smooth and largely debulked with infectious tissue. The surgery was complicated with a small amount of subconjunctival haemorrhage, which resulted from the docking procedure. The pathology test results of the obtained specimen were negative for any organisms, except for positive culture of a N. asteroides complex. Two days after the procedure, drug sensitivities results were available and revealed a multidrug- resistant N. asteroids complex, which was sensitive only to cotrimoxazole and tobramycin. Although, tobramycin and trimethoprim did not improve the infection when used early, he was re-administered tobramycin and trimethoprim/ polymixin B. On postoperative week 3, his vision improved to 20/70 with complete resolution of the infection and trace residual scarring. Author comment: "The greatest risk factor for developing 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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