{'fraction_non_alphanumeric': 0.025523560209424083, 'fraction_numerical': 0.008507853403141362, 'mean_word_length': 5.4759887005649714, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Disseminated Nocardiosis with retinal abscess in a patient treated for bullous pemphigoid

Purpose To report a case of disseminated Nocardiosis with retinal and intracranial lesions. Observations A 49-year-old woman immunosuppressed because of treatment given for bullous pemphigoid presented with altered mental status and multiple intracranial lesions on imaging. The patient was found to have multiple retinal lesions in both eyes, including a subretinal abscess in the right eye. The patient underwent brain biopsy, confirming Nocardia farcinica histopathologically and in culture. Conclusions and Importance Ocular Nocardiosis is a rare disease with varying prognosis that requires prompt diagnosis to ensure appropriate medical therapy.


Introduction
Nocardia are gram positive, aerobic, filamentous bacteria that can cause severe infection in immunocompromised individuals. Disseminated Nocardiosis can be a devastating multi-system disease, including ocular involvement. We wish to report a unique patient with retinal lesions secondary to disseminated Nocardiosis.

Case report
A 49-year-old Caucasian female had altered mental status and headache for 2 days. She had been treated with cyclosporine and prednisone for bullous pemphigoid for several months. The patient's mental status deteriorated and she was sedated and intubated because of a decline in respiratory status. She remained afebrile without leukocytosis. Computed Tomography (CT) of Chest and Abdomen revealed ground glass opacities suggestive of possible right lung pneumonia. Cerebrospinal fluid (CSF) and blood cultures for bacterial, viral, and fungal etiology were negative. The patient was given intravenous vancomycin, piperacillin-tazobactam, and micafungin.
Initial ophthalmic examination of both eyes revealed a quiet anterior segment. Dilated ophthalmoscopic exam revealed a large (2 disc diameter size) elevated subretinal lesion with surrounding hemorrhage in the right eye and multiple small 1/2-1/4 disc diameter size, creamcolored lesions throughout the posterior pole and periphery in both eyes ( Fig. 1A and B). There was no apparent vitritis or inflammation in either eye.
Magnetic Resonance Imaging (MRI) scan revealed numerous small enhancing lesions throughout her brain ( Fig. 2A and B). Brain biopsy and histopathology of one of the enhancing, superficial intracranial lesions revealed filamentous, gram-positive bacteria indicative of Nocardia (Figs. 3 and 4). Fungal cultures yielded Nocardia farcinica. Intravenous imipenem, bactrim, and amikacin were started due to organism sensitivity. Given the possibility of an infectious choroiditis, the following day the patient underwent bilateral vitreous tap-and-inject with amikacin (0.4 mg/0.1 ml). Vitreous gram stain, cultures and polymerase chain reaction were negative. The patient's clinical status slowly improved and, in consultation with infectious disease, she was discharged on systemic bactrim and augmentin for a one year course. Four months after discharge, while continuing treatment, ophthalmic examination revealed visual acuity of 20/100 right eye (OD) and 20/25 left eye (OS). Anterior segment exam findings revealed mild nuclear sclerotic cataracts. Posterior segment exam revealed subretinal fibrosis in macula and superonasally OD and multiple chorioretinal scars in both eyes (OU) (Fig. 5).

Discussion
Ocular infection due to Nocardia is exceedingly rare, with fewer than forty cases of Nocardia endogenous endophthalmitis reported since 1967. 1 Systemically, Nocardia is associated most often with pulmonary infection. 2 Most patients tend to be immunosuppressed, as was this patient. 3,4 Moreover, this patient is the first to be described in the literature to have ocular Nocardiosis after the complications of immunosuppressive treatment with prednisone for bullous pemphigoid. 1 Ocular manifestations of this filamentous, gram-positive bacteria    demonstrate ring-enhancing lesions indicative of Nocardia, as in this patient. 9 In this case, the typical MRI findings together with positive brain biopsy established the clinical diagnosis of Nocardia farcinica, allowing for more appropriate antibacterial management.  1 This patient is one of the few to survive this high mortality disease, stressing the severity and importance of early diagnosis and treatment.

Conclusion
Ocular Nocardiosis is a rare disease often in the setting of immunosuppression and may respond to approved medical therapy after prompt diagnosis.

Patient consent
The patient consented to publication of the case in writing/orally.