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Kocuria Varians CasE REPOrt Kocuria varians – An emerging cause of ocular infections Anita K Videkar1,*, Pranathi B1, Madhuri Gadde1 and Nashrah Nooreen1 1Department of Ophthalmology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad Abstract Purpose: Kocuria varians, which is a nonpathogenic commensal of skin, mucosa and oropharynx. We report a rare case of recurrent conjunctivitis caused by gram positive aerobic microorganism Methods: A 58-year-old male with diabetes mellitus and hypertension presented to us with both eyes recurrent redness, watering, discharge and burning sensation since 3 months. On examination his best corrected visual acuity (BCVA) was 6/9, N6 in right eye and 6/6, N6 in left eye. On anterior segment examination there was upper In view of recurrent conjunctivitis, conjunctival swab was taken and sent for culture and sensitivity. and lower lid edema with matting of lashes, diffuse congestion, chemosis and pseudomembranes in both eyes. Results: culture showedThe organism no growth. was identified as Kocuria varians sensitive to chloramphenicol, gentamycin and resistant to levofloxacin. 2 weeks post treatment with chloramphenicol, patient improved symptomatically and repeat Conclusion: microbiologists to identify and enumerate the virulence and antibiotic susceptibility patterns of such bacteria and for ophthalmologists With increasing in improving reports of theinfections patient associated care and management. with these bacteria, it is now important for clinical Keywords: Kocuria varians; recurrent conjunctivitis; immunocompromised individuals; ocular infection; chloramphenicol *Corresponding author: Dr. Anita K Videkar, DNB resident, Introduction Department of Ophthalmology, KIMS Eye Care, Krishna Institute of Medical Sciences, Minister Road, Secunderabad-500003, Kocuria spp. are gram-positive cocci which are Telangana, India. Mobile no: 7032295273; Email: dr.anitagk@ morphologically similar to both staphylococci and gmail.com the micrococci, usually found as nonpathogenic Received 18 September 2018; Revised 08 November 2018; commensals of skin, mucosa and oropharynx. Accepted 22 November 2018; Published 06 December 2018 Recently there has been a rise in the incidence of infections caused by Kocuria spp. causing both Citation: Videkar AK, Pranathi B, Gadde M, Nooreen N. Kocuria varians – An emerging cause of ocular infections. J Med Sci Res. 2019; 7(1):14-17. DOI: http://dx.doi.org/10.17727/ involving both immunocompromised as well as JMSR.2019/7-4 immunocompetentsuperficial and deep-seated/ individuals. invasive infections Copyright: © 2019 Videkar AK et al. Published by KIMS Foundation and Research Center. This is an open-access article The predisposing factors associated with infections distributed under the terms of the Creative Commons Attribution related to Kocuria spp. include congenital deformities reproduction in any medium, provided the original author and sourceLicense, are which credited. permits unrestricted use, distribution, and cases of total parenteral nutrition), malignancies (short bowel syndrome), chronic catheterization (in 14 Journal of Medical and Scientific Research (ovarian cancer, gastric cancer, myelodysplastic the isolated bacterium showed large gram-positive syndrome, acute myelogenous leukaemia, non- cocci arranged in singles, pairs, short chains, tetrads Hodgkin’s disease) and patients with end-stage and clusters as shown in Figure 2b. The isolated renal disease undergoing continuous ambulatory bacterium was coagulase negative, catalase positive peritoneal dialysis. Other underlying conditions associated with Kocuria infection include diabetes testing using Vitek 2 system showed sensitivity mellitus, tuberculosis, stem cell transplant patients, toand gentamycin was identified (MIC as Kocuria< 4), chloramphenicol varians. Susceptibility (MIC aciduria and pancreatic pseudocyst etc. So far Kocuria spp.patients were suffering found to from be gallstones,associated withmethylmalonic include <4) (Figure 3) and resistance to levofloxacin (MIC urinary tract infections, cholecystitis, catheter- chloramphenicol>8), azithromycin eye (MIC drops >2), and ciprofloxacin tear substitutes (MIC 4 associated bacteremia, dacryocystitis, canaliculitis, times>4), ofloxacin a day. During (MIC 2>8). weeks Patient follow was up treated patient withwas keratitis [1, 2] native valve endocarditis, peritonitis, symptomatically better with subsidence of lid edema and congestion (Figure 4). Repeat conjunctival swab and meningitis. culture from both eyes after 3 weeks showed no descending necrotizing mediastinitis, brain abscess bacterial growth (Figure 5). Thereafter patient was apparently asymptomatic without any history of caused by Kocuria varians in a diabetic patient which recurrence with strict glycemic control. respondedWe present to a treatmentrare case ofwith recurrent chloramphenicol conjunctivitis eye drops based on the culture and sensitivity report. with these bacteria, it is now important for clinical microbiologistsWith increasing toreports identify of infectionsand enumerate associated the virulence and antibiotic susceptibility patterns of such bacteria and for Ophthalmologists in improving the patient care and management. Case report A 58-year-old male visited us with complaints of redness, watering, discharge and blurring of vision in both eyes since last 3 months. He was a known diabetic and hypertensive since last 10 years and on regular medications. Prior to visiting Right eye tobramycin and prednisolone eye drops without any symptomaticus he was treated relief. withEarlier moxifloxacin, culture and loteprednol, sensitivity report 2 months following conjunctivitis showed no growth. At presentation his best corrected visual acuity was 6/9 N6 in right eye and 6/6 N6 in left eye respectively. On slit lamp biomicroscopy examination there was upper and lower lid oedema with matting of lashes, in both eyes. In view of recurrent conjunctivitis conjunctivaldiffuse congestion, swabs chemosis, were taken and pseudomembranesfrom both eyes upper and lower fornices and sent for culture and sensitivity. The sample was incubated at 37o C for 48 Left eye hours on blood agar, culture on blood agar revealed Figure 1: Anterior segment photographs showing small round, raised, convex, whitish colony with no formation in both eyes. haemolysis as shown in Figure 2a. Gram’s stain of chemosis, diffuse congestion and pseudomembrane Vol. 7 | Issue 1 | January - March 2019 15 Right eye Figure 2: (a) Blood agar culture plate small round raised, convex, whitish colony with no hemolysis, (b) Gram’s stain pairs, short chains, tetrads, clusters. of Kocuria varians showing large sized cocci arranged in Left eye Figure 4: Anterior segment photographs post treatment after 2 weeks. Figure 3: Culture and sensitivity report showing Kocuria Figure 5: Culture and sensitivity report showing no growth varians organism isolated from conjunctival swab and its 3 weeks post treatment. sensitivity to gentamycin and chloramphenicol. In the clinical microbiology laboratory this Discussion Kocuria spp. is Gram-positive cocci arranged in negative Staphylococci (CoNS) based on its bacterium is normally misidentified as coagulase- pairs, short chains, tetrads, cubical packets of gram reaction, catalase positive and coagulase eight and irregular clusters. Kocuria belongs to negative properties. Other physiological and the phylum Actinobacteria, class Actinobacteria, biochemical properties of Kocuria are the formation order Actinomycetales, sub order Micrococcinae and of non-hemolytic colonies on blood agar, non- family Micrococcaceae [3]. This bacterium was capsulated, non-spore forming, non-motile, non- acid fast and positive for Voges-Proskauer test Slovakian microbiologist. Currently, there are more (VP). It has also been observed that various species first identified and described by Miroslav Kosur, a the 16S rRNA phylogenetic studies [4]. These are tests like the oxidase, amylase, urease, citrate of Kocuria react differently to routine biochemical nonpathogenicthan 18 species commensals of Kocuria found identified on the based skin andon mucous membrane of human and animals. utilization test, gelatinase, phosphatase tests, 16 utilization ofJournal inulin, of arabinose, Medical and N-acet Scientificyl-L-glutamic Research acid, and nitrate reduction test [5]. This could be Acknowledgement attributed to the reason behind the inaccurate Our sincere thanks to Dr. Anil Kumar Bilolikar, Senior Consultant, Microbiology Department, Dr. identification by both conventional and an automated bacterial identification systems. Poonam and all Microbiology department staff for systems that include VITEK (BioMe´rieux Inc., Durham, department.their co-operation and support. We are also thankful With the availability of new automated identification to all optometrists and staff of Ophthalmology Conflict of interest theNC, BDUSA), Phoenix™ VITEK 2Automated (BioMe´rieux Microbiology Inc., Durham, System NC, USA), API (BioMe´rieux Inc., Durham, NC, USA) and Authors declare no conflict of interest. from(BD Diagnostic CoNS and Systems, identify Sparks, all species MD) identification of Kocuria References [6].systems, In the it iscase now ofpossible non-availability to differentiate of molecular Kocuria [1] Matterm RM, Ding J. Keratitis with Kocuria palustris and and advanced laboratory methods, Kocuria can Ophthalmol. 2014; 27:72–77. Rothia mucilaginosa in vitamin A deficiency. Case Rep from Staphylococci and Micrococci using morphological,still
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