Endogenous Nocardia Nova Panophthalmitis Masquerading as Malignancy: A Clinicopathologic Report

To report a case of pathology-confirmed endogenous Nocardia nova panophthalmitis that presented as a choroidal lesion and orbital signs in a patient with history of presumed left renal cell carcinoma and right renal transplant on chronic immunosuppression.

Retrospective chart review of a case.

A 71-year-old woman with right renal transplant on tacrolimus, presumed left renal cell carcinoma, and recent Aspergillus fumigatus nodular pneumonia presented with subacute right eye pain, eyelid swelling, counting fingers vision, a quiet anterior chamber, posterior synechiae, mild vitritis, and an amelanotic choroidal mass with low internal reflectivity. She was not on treatment for her presumed renal cancer and denied infectious symptoms. Orbital imaging showed abnormal enhancement extending from the mass into the retro-orbital fat. Systemic work-up showed a new mass arising from the transplanted right kidney, with fine-needle aspiration biopsy showing filamentary bacilli and broad-range polymerase chain reaction (PCR) positive for Nocardia nova. The patient underwent enucleation of the right eye, which showed panophthalmitis and a choroidal abscess with Nocardia filamentary bacilli. There were no signs of orbital inflammation after the post-operative month 2 visit.

In patients on chronic immunosuppression, endogenous nocardiosis should be considered in the setting of an intraocular mass and orbital inflammation, even in the absence of leukocytosis or systemic symptoms. Early recognition and appropriate management may improve systemic outcomes in Nocardia infections, even when enucleation becomes necessary for local disease control.