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Year : 2004  |  Volume : 22  |  Issue : 2  |  Page : 123-125

Nocardia asteroides canaliculitis: A case report of uncommon aetiology

Department of Microbiology, Aravind Eye Care System, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli - 627 001, Tamil Nadu, India

Correspondence Address:
Department of Microbiology, Aravind Eye Care System, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli - 627 001, Tamil Nadu, India

 ~ Abstract 

Ocular nocardiosis is an opportunistic infection and is believed to be a rare entity. We describe a rare case report of a patient with culture-positive Nocardia asteroides canaliculitis who presented with complaints of watering, purulent discharge and painful swelling of left lower eye lid. A purulent tenacious material was expressed from the punctum of lower eye lid and subjected to microbiological investigations such as smears and cultures. Smears and culture proved the presence of Nocardia asteroides in the sample collected from punctum.

How to cite this article:
Bharathi M J, Ramakrishnan R, Meenakshi R, Vasu S. Nocardia asteroides canaliculitis: A case report of uncommon aetiology. Indian J Med Microbiol 2004;22:123-5

How to cite this URL:
Bharathi M J, Ramakrishnan R, Meenakshi R, Vasu S. Nocardia asteroides canaliculitis: A case report of uncommon aetiology. Indian J Med Microbiol [serial online] 2004 [cited 2020 Nov 24];22:123-5. Available from:

Canaliculitis is a relatively uncommon chronic unilateral infection of the lacrimal canaliculus.[1] Bacteria, fungi and viruses may all produce such infection[1] the most common agents reportedly being Actinomyces.[1],[2],[3] The laboratory diagnosis of definite aetiology of canaliculitis is difficult, because secondary contaminants frequently obscure the real aetiology, and it may be hard to recognise on smear or grow on culture.[2] The ocular manifestations of Nocardia include persistent epithelial defect, conjunctivitis, dacryocystitis, scleritis, keratitis, episcleral granuloma and endophthalmitis.[4] In this report, we describe a case report of a patient with culture-positive Nocardia asteroides canaliculitis.

 ~ Case Report Top

A 55 year old lady presented to us with complaints of watering and purulent discharge from left eye for 3 months, pain and swelling of the left lower eye lid for one week [Figure - 1]. She gave a history of fall of soil in her left eye three months ago. On examination her vision was 6/6 in right eye and 6/12 in left eye. Examination of left eye showed swelling of left lower eye lid which was tender. The swelling was in the medial one third of the left lower eye lid and the neighbouring part of the conjunctiva was inflamed. The saline irrigation through upper punctum showed the lacrimal sac and nasolacrimal duct to be patent and there was no tenderness and swelling in the lacrimal sac area. The lower punctum was found to be pouting with expression of tenacious pus on pressure over the swelling and rest of the anterior and posterior segment was normal in left eye. The right eye was normal. The punctum was split under topical anaesthesia using a fine scissors taking aseptic precautions and a thick, tenacious purulent material was expressed from the canaliculus. The concretion was removed by performing a linear section into the conjunctival surface of the canaliculus followed by irrigation with penicillin G solution (100, 000 units). The patient was also treated with ciprofloxacin eye ointment and drops for 3 weeks. The punctal discharge was collected for microbiological investigations. A portion of collected material was inoculated on Sabouraud dextrose agar (SDA) without cycloheximide, 10% sheep blood agar, chocolate agar and also a deep inoculation was done in thioglycollate broth and brain heart infusion broth.[5] SDA was incubated at 25C and examined daily for upto 3 weeks.[5] The remaining inoculated media were incubated at 37C and examined daily for upto 7 days.[5] All laboratory methods followed standard protocols.[5] Microbial cultures were considered positive only if the following criteria were met:
The other portion of the collected material was smeared for 10% potassium hydroxide (KOH) wet mount, Gram staining and Kinyoun's acid-fast staining. A 10% KOH revealed very fine, intertwined, narrow, delicate branching filaments [Figure - 2]. On Gram staining the organisms appeared gram-positive beaded, coccoid, thin branching filaments. In Kinyoun's acid-fast staining the organisms were seen as thin, acid-fast, branching filaments [Figure - 3]. All direct microscopic examinations were suggestive of Nocardia morphology. On culture, the colonies appeared as white, dry, chalky, rough, raised, folded and irregular [Figure:4]. The isolate was further identified by standard bacteriological methods.[5] Antibacterial susceptibility of isolated Nocardia aesteroides isolate was determined by the Kirby-Bauer disc-diffusion method[7] and the result of this testing showed that the organism was susceptible to ciprofloxacin, gentamicin, vancomycin and chloramphenicol, and resistant to cefazolin, co-trimoxazole and norfloxacin.
The patient recovered rapidly and was left with a slit punctum and adjoining canaliculus. The remaining portion of the lower canaliculus was intact and was patent. Post-operatively, the patient had no purulent discharge.

 ~ Discussion Top

Nocardia asteroides are gram-positive, non-motile, non-sporing, non-capsulated and slow growing organisms.[5],[6] They are acid-fast to 1% sulfuric acid and are stained by Kinyoun's technique.[5],[6] Nocardia do not have complex growth requirements. They grow well on most commonly used bacteriological media. They usually require a minimum of 48 to 72 hours before colonies become visible.
The general manifestations of the Nocardia infections are mycetoma, pulmonary changes with generalized metastasis.[6] Extrapulmonary nocardiosis involving skin and brain are common. Nocardia infection of any type involving the eye is rare.[6] Nocardia corneal or adnexal infection usually occurs following trauma especially if there is contamination with soil.[4] It is often seen in patients living in rural India with agriculture as main occupation. The source of infection could be from soil, organic matter or animals. Our patient with Nocardia canaliculitis was a farmer and she had history of fall of soil and organic manure in her left eye three months ago. Some studies point out the delay in the diagnosis and difficulty in the identification of Nocardia infection in the diagnostic laboratory.[4] Although, 10% KOH wet mount preparation is simple, sensitive conventional method for early detection of Nocardia, Kinyoun's acid-fast stain helps to differentiate the Nocardia species from Actinomyces species by its acid-fastness.[1] It grows in ordinary media like SDA, sheep blood agar and thiglycollate broth at 25C and 37C within 3 to 7 days.
Concretions on the lacrimal canaliculus have been considered to be due to Candida albicans, Aspergillus niger, Fusobacterium species, and most frequently Actinomyces species.[1],[2] The genus Actinomyces inhabit the mouth and tonsils of some person and could enter the lacrimal system through the nosal passages or indirectly by means of saliva into the conjunctiva. The anaerobic environment is also condutive to growth of the Actinomyces in the canaliculus.[2] Anaerobic Fusobacterium species has been reported as a cause of canaliculitis.[7] The literature search of canaliculitis shows that Nocardia infection of canaliculus is uncommon. Previously Nocardia asteroides has been reported as a aetiology of lacrimal infection by Penkett et al in 1942.[8]
Actinomyces, Fusobacterium, and Nocardia may be confused when identification is based on the microscopic appearance of Gram stained materials.[7] Sometimes non-sporeforming gram positive bacilli tend to loose their affinity for crystal violet when stained by Gram stain method, which can lead to incorrect identification of an isolate as the gram negative Fusobacterium species.[7] Because of the similar morphology and Gram staining characteristics it is difficult to provide definite identification of the responsible organisms by direct microscopic examination.[7] However the aerobic nature and 1% acid fast characteristics of Nocardia species help to differentiate from the other gram positive, non-sporeforming anaerobic bacilli such as Actinomyces species and Fusobacterium species.[3],[8] 

 ~ References Top

1.Jordan DR. Dacryoadenitis, Dacryocystiti, and Canaliculitis, chapter 57. In: Cornea- Cornea and External Disease: Clinical Diagnosis and Management. Krachmer JH, Mannis MJ, Holland EJ, Eds. (St. Louis, Mosby). 1997;687-693.   Back to cited text no. 1    
2.Richards WW. Actinomycotic lacrimal canaliculitis. American J Ophthalmol 1975;75:155-157.  Back to cited text no. 2    
3.Pine L, Hardin H, Turner L, Roberts SS. Actinomycotic lacrimal canaliculitis - A report of two cases with a review of the characteristics which identify the causal organism. American J Ophthalmol 1960;49:1278-1298.   Back to cited text no. 3    
4.Sridhar MS, Gopinathan U, Garg P, Sharma S, Rao GN. Ocular Nocardia infections with special emphasis on the cornea. Surv Ophthalmol 2001;45:361-378.  Back to cited text no. 4    
5.Sharma S. Ocular Microbiology. 1st ed. (Aravind Eye Hospitals Publication, Madurai) 1988:79-84.  Back to cited text no. 5    
6.Gordon MA. Aerobic pathogenic Actinomycetaceae. Chapter 23. In: Manual of Clinical Microbiology, 4th ed. Lennette EH, Balows A, Hausler WJ, Shadomy HJ, Eds. (American Society for Microbiology, Washington DC) 1985:249-262.  Back to cited text no. 6    
7.Weinberg RJ, Sartoris MJ, Buerger GF, Novak JF. Fusobacterium in presumed Actinomyces canaliculitis. American J Ophthalmol 1977;84:371-374.  Back to cited text no. 7    
8.Penikett EJK, Rees DL. Nocardia asteroides infection of the nasal lacrimal system. American J Ophthalmol 1962;53:1006-1008.  Back to cited text no. 8    
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2004 - Indian Journal of Medical Microbiology
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