Vol. 114, No. 3
Letters to The Journal
Preseptal Cellulitis Caused by Nocardia brasiliensis Lee R. Hunter, M.D., Andrew H. Krinsky, M.D., and Carola H. Fleener, M.D. Sarasota, Florida. Inquiries to Lee A. Hunter, M.D., Eye Specialists, 1428 S. Tamiami Trail, Sarasota, FL 34239. Nocardia species represent an uncommon group of pathogens responsible for a wide vari ety of skin and systemic infections. 1-3 We treated a patient who had clinical signs of preseptal cellulitis at initial examination and who even tually developed culture-proven Nocardia ab scesses. The patient was an 11-year-old boy first seen by his local physician one week after manipula tion of a skin pustule below the lateral right lower eyelid by his mother. Records indicated that at initial examination moderate edema and erythema were present in the right upper and lower eyelids and some surrounding skin. There was also a slight amount of purulent eyelid margin discharge. At that time, preseptal cellulitis was diagnosed. Blood culture, conjunctival swab culture, and a complete blood cell count were performed. Treatment with an intramuscular injection of ceftriaxone along with oral cefaclor was begun. The patient con tinued oral medication for two days and re turned to one of us (C.H.F.) for follow-up. A history of worsening periocular edema, pain, and erythema of the right preseptal area was obtained, and an indurated area of the inferolateral right lower eyelid was noted on physical examination. The patient was referred that day for ophthalmic consultation to one of us (L.R.H.). His visual acuity was 20/20 in each eye. The globe was normal. There was a 10 x 5 x 3-mm fluctuant subcutaneous abscess of the inferolateral right lower eyelid. Edema and erythema extended from this area to involve the entire ocular adnexa, creating the appearance of pre septal cellulitis. Approximately 3 cm posterior to the lateral orbital rim, another subcutaneous fluctuant area could be palpated. This lesion was 10 mm in diameter, and was elevated 4 mm. It was surrounded by less intense skin inflammation. There was a raised, enlarged, and tender preauricular lymph node. Moderate submandibular lymphadenopathy was noted. Orbital computed tomography showed strictly subcutaneous involvement and reflected the
373
marked edema of the preseptal area and the two subcutaneous abscesses. The patient was taken to the operating room and given general anes thesia. Careful inspection of the two abscesses disclosed small skin drainage sites, which would allow expression of only small amounts of purulent material with massage. Small inci sions through these sites with a blade into the fluctuant abscess disclosed a moderate amount of purulent material that was sent for culture and sensitivity testing. A sterile drain was left at each site. For the next two days, the patient was treated with intravenous nafcillin and cefotaxime. Although the abscesses did not redevelop, there was little clinical improve ment. Initial results of the conjunctival culture disclosed Enterobacter aerogenes and E. cloacae. Infectious disease consultation was obtained (A.H.K.), and treatment with nafcillin was changed to oral trimethoprim and oral sulfamethoxazole. By the next day, the preseptal edema had improved moderately. The next day, the initial culture of the surgical specimen dis closed Nocardia organisms. Treatment with cefotaxime was then discontinued and amikacin was administered intravenously. The infec tion eventually was confirmed to be caused by N. brasiliensis. For the next three days the clini cal signs decreased to normal and the drains were pulled. Treatment with amikacin was dis continued and the patient was discharged to continue oral trimethoprim and sulfamethoxazole therapy. At no point in the clinical course was the patient febrile. Several features of this case are consistent with the nocardial skin infections described in the literature. The cause is often a contaminat ed skin wound. In our patient the presence of two Enterobacter species in the conjunctival culture indicated the poor hygiene with which his eye was treated. The infection is usually slow, progressive, and often creates multiple subcutaneous abscesses in a line. This has been referred to as sporotrichoid nocardiosis. 4 Lymph node involvement is usually marked. Drainage through the skin from the abscess may be present. The clinical features that dis tinguished our case from the usual manifesta tion of preseptal cellulitis were the subcutane ous abscesses, which were not found before the day of admission, and marked lymphadenopa thy of both the preauricular and submandibular area. This case did share features with preseptal cellulitis secondary to skin wound in general. Nocardia organisms should be considered in patients who have preseptal cellulitis with fea-
374
AMERICAN JOURNAL OF OPHTHALMOLOGY
tures of isolated areas of subcutaneous indura tion and lymphadenopathy at initial examina tion. Recognition is important, because the choice of antibiotics for nocardial infection dif fers markedly from the choice of antibiotics for the usual organisms creating preseptal cellulitis.
References 1. Smego, R. A., Jr., and Gallis, H. A.: The clinical spectrum of Nocardia brasiliensis infection in the United States. Rev. Infect. Dis. 6:164, 1984. 2. Tsuboi, R., Takamori, K.; Ogawa, H., Mikami, Y., and Arai, T.: Lymphocutaneous nocardiosis caused by Nocardia astéroïdes. Arch. Dermatol. 122:1183, 1986. 3. Gregor, R. ]., Chong, C. A., Augsburger, J. ]., Eagle, R. C, Jr., Carlson, K. M., Jessup, M., Wong, S., and Naids, R.: Endogenous Nocardia astéroïdes subretinal abcess diagnosed by transvitreal fine-needle aspiration biopsy. Retina 9:118, 1989. 4. Moore, M., and Conrad, A. H.: Sporotrichoid nocardiosis caused by Nocardia brasiliensis. Arch. Dermatol. 95:390, 1967.
Brucellosis and Uveitis Jonathan Walker, M.D., Om F. Sharma, M.D., and Narsing A. Rao, M.D. University of Southern California School of Medicine and Doheny Eye Institute. Inquiries to Narsing A. Rao, M.D., Doheny Eye Institute, 1355 San Pablo St., Los Angeles, CA 90033. Brucellosis is a bacterial infection transmittable from animals to humans, mainly through exposure to infected carcasses, abortus, and unpasteurized dairy products. With the advent of modern animal health measures and pasteur ization, the incidence has declined dramatical ly, although cases are still described (131 cases in 1984).' Brucellosis was once considered an important cause of uveitis, and is still diag nosed occasionally in more rural countries. 2 However, as the incidence of brucellosis has declined, so has the diagnosis of the related uveitis, and recent discussions usually refer to the previous literature for descriptions. 35 Given the scarcity of cases and the uncertainty of the previous diagnostic techniques, some authori ties have questioned whether brucellosis truly
September, 1992
causes uveitis. 3,4 We recently managed a case of brucellosis that did lead to uveitis, and we suggest that Bruceila organisms be considered a potential, albeit uncommon, cause of uveitis. A 56-year-old man had a ten-week history of recurrent fevers, night sweats, and right upper quadrant pain at referral to our institution. He had a history of travel to many rural areas, but he denied any known exposure to sick animals or suspect foods. At initial examination, he had already undergone an extensive examination at several medical facilities that culminated in a liver biopsy that showed necrotizing granulomas. He had been treated empirically with ampicillin, metronidazole, isoniazid, and rifampin for various presumed causes of disease without effect. The diagnosis of brucellosis was entertained and titers for Bruceila organisms were positive at 1:640. Treatment was begun with tetracycline and within two weeks, he had recovered and was back at work. Follow-up titers were 1:80. After three weeks of treatment, he noted floaters and cloudy vision. He was treated with topical corticosteroids for bilateral iritis, and he was referred to the uveitis service at Doheny Eye Institute. On examination, his visual acuity was R.E.: 20/50 and L.E.: 20/40. Scattered pigmented keratic precipitates and posterior synechiae were present in both eyes. The anterior chambers were uninflamed (he was using topical corticosteroids) but he had moderate anterior vitreous cells; there was mild disk hyperemia and scattered yellow, round choroidal lesions in the periphery of each eye (Figure). Because he had already had a full systemic examination, no additional testing was deemed necessary. He was treated with a six-month tapered dose of oral and topical corticosteroids, to which he had a good re sponse. He had one brief recurrence of uveitis two years later that responded quickly to topi cal treatment. He ultimately developed posteri or subcapsular cataracts and underwent un complicated extracapsular cataract extraction and posterior chamber lens implantations; he has had no further episodes of uveitis and has remained in good health. Patients with brucellosis usually have sys temic symptoms of malaise, fevers, chills, night sweats, headaches, and arthralgias at initial examination. The acute phase, if not treated, can become chronic or relapsing.' The diagno sis is based largely on the clinical signs and symptoms and on positive titers; skin tests are
Letters to The Journal
Preseptal Cellulitis Caused by Nocardia brasiliensis Lee R. Hunter, M.D., Andrew H. Krinsky, M.D., and Carola H. Fleener, M.D. Sarasota, Florida. Inquiries to Lee A. Hunter, M.D., Eye Specialists, 1428 S. Tamiami Trail, Sarasota, FL 34239. Nocardia species represent an uncommon group of pathogens responsible for a wide vari ety of skin and systemic infections. 1-3 We treated a patient who had clinical signs of preseptal cellulitis at initial examination and who even tually developed culture-proven Nocardia ab scesses. The patient was an 11-year-old boy first seen by his local physician one week after manipula tion of a skin pustule below the lateral right lower eyelid by his mother. Records indicated that at initial examination moderate edema and erythema were present in the right upper and lower eyelids and some surrounding skin. There was also a slight amount of purulent eyelid margin discharge. At that time, preseptal cellulitis was diagnosed. Blood culture, conjunctival swab culture, and a complete blood cell count were performed. Treatment with an intramuscular injection of ceftriaxone along with oral cefaclor was begun. The patient con tinued oral medication for two days and re turned to one of us (C.H.F.) for follow-up. A history of worsening periocular edema, pain, and erythema of the right preseptal area was obtained, and an indurated area of the inferolateral right lower eyelid was noted on physical examination. The patient was referred that day for ophthalmic consultation to one of us (L.R.H.). His visual acuity was 20/20 in each eye. The globe was normal. There was a 10 x 5 x 3-mm fluctuant subcutaneous abscess of the inferolateral right lower eyelid. Edema and erythema extended from this area to involve the entire ocular adnexa, creating the appearance of pre septal cellulitis. Approximately 3 cm posterior to the lateral orbital rim, another subcutaneous fluctuant area could be palpated. This lesion was 10 mm in diameter, and was elevated 4 mm. It was surrounded by less intense skin inflammation. There was a raised, enlarged, and tender preauricular lymph node. Moderate submandibular lymphadenopathy was noted. Orbital computed tomography showed strictly subcutaneous involvement and reflected the
373
marked edema of the preseptal area and the two subcutaneous abscesses. The patient was taken to the operating room and given general anes thesia. Careful inspection of the two abscesses disclosed small skin drainage sites, which would allow expression of only small amounts of purulent material with massage. Small inci sions through these sites with a blade into the fluctuant abscess disclosed a moderate amount of purulent material that was sent for culture and sensitivity testing. A sterile drain was left at each site. For the next two days, the patient was treated with intravenous nafcillin and cefotaxime. Although the abscesses did not redevelop, there was little clinical improve ment. Initial results of the conjunctival culture disclosed Enterobacter aerogenes and E. cloacae. Infectious disease consultation was obtained (A.H.K.), and treatment with nafcillin was changed to oral trimethoprim and oral sulfamethoxazole. By the next day, the preseptal edema had improved moderately. The next day, the initial culture of the surgical specimen dis closed Nocardia organisms. Treatment with cefotaxime was then discontinued and amikacin was administered intravenously. The infec tion eventually was confirmed to be caused by N. brasiliensis. For the next three days the clini cal signs decreased to normal and the drains were pulled. Treatment with amikacin was dis continued and the patient was discharged to continue oral trimethoprim and sulfamethoxazole therapy. At no point in the clinical course was the patient febrile. Several features of this case are consistent with the nocardial skin infections described in the literature. The cause is often a contaminat ed skin wound. In our patient the presence of two Enterobacter species in the conjunctival culture indicated the poor hygiene with which his eye was treated. The infection is usually slow, progressive, and often creates multiple subcutaneous abscesses in a line. This has been referred to as sporotrichoid nocardiosis. 4 Lymph node involvement is usually marked. Drainage through the skin from the abscess may be present. The clinical features that dis tinguished our case from the usual manifesta tion of preseptal cellulitis were the subcutane ous abscesses, which were not found before the day of admission, and marked lymphadenopa thy of both the preauricular and submandibular area. This case did share features with preseptal cellulitis secondary to skin wound in general. Nocardia organisms should be considered in patients who have preseptal cellulitis with fea-
374
AMERICAN JOURNAL OF OPHTHALMOLOGY
tures of isolated areas of subcutaneous indura tion and lymphadenopathy at initial examina tion. Recognition is important, because the choice of antibiotics for nocardial infection dif fers markedly from the choice of antibiotics for the usual organisms creating preseptal cellulitis.
References 1. Smego, R. A., Jr., and Gallis, H. A.: The clinical spectrum of Nocardia brasiliensis infection in the United States. Rev. Infect. Dis. 6:164, 1984. 2. Tsuboi, R., Takamori, K.; Ogawa, H., Mikami, Y., and Arai, T.: Lymphocutaneous nocardiosis caused by Nocardia astéroïdes. Arch. Dermatol. 122:1183, 1986. 3. Gregor, R. ]., Chong, C. A., Augsburger, J. ]., Eagle, R. C, Jr., Carlson, K. M., Jessup, M., Wong, S., and Naids, R.: Endogenous Nocardia astéroïdes subretinal abcess diagnosed by transvitreal fine-needle aspiration biopsy. Retina 9:118, 1989. 4. Moore, M., and Conrad, A. H.: Sporotrichoid nocardiosis caused by Nocardia brasiliensis. Arch. Dermatol. 95:390, 1967.
Brucellosis and Uveitis Jonathan Walker, M.D., Om F. Sharma, M.D., and Narsing A. Rao, M.D. University of Southern California School of Medicine and Doheny Eye Institute. Inquiries to Narsing A. Rao, M.D., Doheny Eye Institute, 1355 San Pablo St., Los Angeles, CA 90033. Brucellosis is a bacterial infection transmittable from animals to humans, mainly through exposure to infected carcasses, abortus, and unpasteurized dairy products. With the advent of modern animal health measures and pasteur ization, the incidence has declined dramatical ly, although cases are still described (131 cases in 1984).' Brucellosis was once considered an important cause of uveitis, and is still diag nosed occasionally in more rural countries. 2 However, as the incidence of brucellosis has declined, so has the diagnosis of the related uveitis, and recent discussions usually refer to the previous literature for descriptions. 35 Given the scarcity of cases and the uncertainty of the previous diagnostic techniques, some authori ties have questioned whether brucellosis truly
September, 1992
causes uveitis. 3,4 We recently managed a case of brucellosis that did lead to uveitis, and we suggest that Bruceila organisms be considered a potential, albeit uncommon, cause of uveitis. A 56-year-old man had a ten-week history of recurrent fevers, night sweats, and right upper quadrant pain at referral to our institution. He had a history of travel to many rural areas, but he denied any known exposure to sick animals or suspect foods. At initial examination, he had already undergone an extensive examination at several medical facilities that culminated in a liver biopsy that showed necrotizing granulomas. He had been treated empirically with ampicillin, metronidazole, isoniazid, and rifampin for various presumed causes of disease without effect. The diagnosis of brucellosis was entertained and titers for Bruceila organisms were positive at 1:640. Treatment was begun with tetracycline and within two weeks, he had recovered and was back at work. Follow-up titers were 1:80. After three weeks of treatment, he noted floaters and cloudy vision. He was treated with topical corticosteroids for bilateral iritis, and he was referred to the uveitis service at Doheny Eye Institute. On examination, his visual acuity was R.E.: 20/50 and L.E.: 20/40. Scattered pigmented keratic precipitates and posterior synechiae were present in both eyes. The anterior chambers were uninflamed (he was using topical corticosteroids) but he had moderate anterior vitreous cells; there was mild disk hyperemia and scattered yellow, round choroidal lesions in the periphery of each eye (Figure). Because he had already had a full systemic examination, no additional testing was deemed necessary. He was treated with a six-month tapered dose of oral and topical corticosteroids, to which he had a good re sponse. He had one brief recurrence of uveitis two years later that responded quickly to topi cal treatment. He ultimately developed posteri or subcapsular cataracts and underwent un complicated extracapsular cataract extraction and posterior chamber lens implantations; he has had no further episodes of uveitis and has remained in good health. Patients with brucellosis usually have sys temic symptoms of malaise, fevers, chills, night sweats, headaches, and arthralgias at initial examination. The acute phase, if not treated, can become chronic or relapsing.' The diagno sis is based largely on the clinical signs and symptoms and on positive titers; skin tests are
