Nocardia asteroides sclerokeratitis in a contact lens wearer

To report a case of sclerokeratitis caused by Nocardia asteroides in a soft contact lens wearer.

A 65-year-old male presented with a 2-month history of a corneal ulcer in the left eye. He wore two weekly disposable soft contact lenses on an extended basis. He revealed his history of gardening before the onset of symptoms. On examination, his best-corrected visual acuity was 20/30 in the right eye and 20/400 in the left eye. In the left eye, there was conjunctival injection. His cornea showed multiple patchy infiltrates, with a feathery border that was raised and involved up to the midstroma. There was a 3+ anterior chamber reaction. Corneal scrapings were performed for smears and cultures. Topical 2% amikacin sulfate every half hour along with oral clarithromycin therapy was initiated. On follow-up, the sclera lesions worsened.

Smears of corneal scrapings revealed gram-positive filamentous bacteria in Gram's stain. The cultures grew Nocardia asteroides. The patient was switched to trimethoprim-sulfamethoxazole (Bactrim DS, Roche Laboratories, Nutley, NJ) as the sclera was involved. The patient responded to treatment, and the infection resolved. When last seen, approximately 4 months after his initial presentation to us, his visual acuity was 20/40 in the affected eye. There was corneal scarring, and the adjacent sclera showed thinning.

Nocardia sclerokeratitis can be associated with contact lens wear. Nocardia should be considered in the differential diagnosis of a corneal ulcer with an indolent progressive course with feathery infiltrates. Topical amikacin and systemic trimethoprim-sulfamethoxazole are effective drugs in the treatment of nocardial corneal infection with scleral involvement.