Diagnostic Challenges in Nocardia Keratitis

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Objective:To present a case of diagnostic confusion in Nocardia keratitis in a contact lens wearer and to illustrate the characteristic clinical findings of this rare entity.Methods:Case report of Nocardia keratitis that was mistaken for acanthamoeba, herpetic, and fungal keratitis in three tertiary corneal referral centers before the correct diagnosis of Nocardia infection was made.Results:A 29-year-old contact lens wearer was referred to our hospital for a contact lens–associated bacterial keratitis, not improving under standard bacterial treatment. Biomicroscopy revealed a circular corneal ulcer and pinhead lesions arranged in a wreath pattern. Initial scraping revealed no positive cultures and confocal microscopy findings were suspicious for fungal keratitis. Only after a poor response to protozoal and fungal treatment, and a negative herpes serology, Nocardia was suspected. This suspicion was confirmed with a positive culture and the topical amikacin and ciprofloxacin were started. The infiltrate responded promptly and resolved, leaving a small corneal scar and a good visual recovery.Conclusion:Because of its infrequent occurrence and its variable clinical picture, Nocardia keratitis is easily misdiagnosed. Although a rare entity, this infection should be added to the differential diagnosis in contact lens–related keratitis not responding to first-line antibiotics and presenting with patchy anterior stromal infiltrates.

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