A case report of ocular nocardiosis secondary to Nocardia asiatica in a patient with acquired immunodeficiency syndrome

Purpose To describe the clinical presentation, diagnosis, management, and outcome of endogenous ocular nocardiosis caused by Nocardia asiatica in a profoundly immunocompromised patient. Observations A 27-year-old man with acquired immunodeficiency syndrome presented with encephalopathy, severe immunosuppression, and innumerable ring-enhancing brain lesions concerning for disseminated opportunistic infection. Ophthalmic examination revealed bilateral subretinal abscesses and deposits without vitreous inflammation, as well as a macula-involving exudative retinal detachment in the right eye. Extensive microbiologic evaluation, including anterior chamber polymerase chain reaction testing, was unrevealing. Progressive neurologic decline prompted craniotomy with brain biopsy, which demonstrated branching filamentous organisms on Grocott methenamine silver staining, with molecular sequencing confirming Nocardia asiatica . Targeted trimethoprim-sulfamethoxazole therapy resulted in systemic and neurologic improvement with consolidation of subretinal lesions. Final visual acuity remained severely limited in the macula-involved right eye but recovered to 20/20 in the left eye. Conclusions and Importance This case represents a detailed report of endogenous ocular nocardiosis attributable to Nocardia asiatica presenting as bilateral subretinal abscesses with multifocal brain involvement. Subretinal abscess-like lesions with minimal intraocular inflammation in the setting of disseminated infection, particularly when accompanied by multifocal brain abscesses, should prompt early consideration of nocardiosis. Early recognition and empiric trimethoprim-sulfamethoxazole therapy may facilitate systemic recovery and preserve vision in less affected eyes.