Unusual Microbiological Presentations in Polymicrobial Post-Operative Endophthalmitis and Their Clinical Correlations

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Unusual Microbiological Presentations in Polymicrobial Post-Operative Endophthalmitis and Their Clinical Correlations Int Ophthalmol (2019) 39:2143–2148 https://doi.org/10.1007/s10792-018-1019-7 (0123456789().,-volV)(0123456789().,-volV) CASE REPORT Unusual microbiological presentations in polymicrobial post-operative endophthalmitis and their clinical correlations Sanchita Mitra . Tapas Ranjan Padhi . Soumyava Basu . Smruti Rekha Priyadarshini . Savitri Sharma Received: 26 April 2018 / Accepted: 11 September 2018 / Published online: 17 September 2018 Ó Springer Nature B.V. 2018 Abstract cornea and vitreous cavity, respectively) isolated had Purpose To report the clinical course, microbiolog- different sensitivity patterns. In case 3, two different ical spectrum and visual outcomes of three cases of strains of the same organism (Enterococcus faecalis) post-operative endophthalmitis caused by unusual were found. Cases 1 and 2 achieved good anatomical combination of micro-organisms. and visual outcomes, while in case 3, vision remained Methods Retrospective review of medical charts at a poor despite a good anatomical outcome. tertiary eye care centre over a period of 1 year, of Conclusion Unusual combinations of organisms in subjects with post-operative endophthalmitis and post-operative endophthalmitis can introduce unique more than one microbiological isolate. clinical characteristics and should specifically be Results We report 3 cases with unusual combination considered in atypical clinical presentations, poor of microorganisms. In case 1, two organisms response to standard therapy and unusual recurrence (Burkholderia cepacia and Aeromonas veronii, from patterns. the vitreous cavity and capsular bag, respectively) with an identical antibiotic sensitivity pattern were Keywords Polymicrobial Á Endophthalmitis Á found, while in case 2, the organisms (Streptococcus Antimicrobial resistance pneumoniae and Sphingomonas paucimobilis, from S. Mitra (&) Introduction Microbiology Service, L V Prasad Eye Institute, MTC Campus, Patia, Bhubaneswar, Odisha 751024, India Microbiological identification of causative organisms e-mail: [email protected] is crucial for appropriate diagnosis and management T. R. Padhi Á S. Basu of any form of endophthalmitis [1]. Conventional Retina and Uveitis Service, L V Prasad Eye Institute, microbiological techniques generally reveal a single MTC Campus, Bhubaneswar, Odisha, India causative organism from ocular samples in majority of S. R. Priyadarshini the cases [2]. Polymicrobial infection has also been Cornea Service, L V Prasad Eye Institute, MTC Campus, reported in different forms of endophthalmitis [3–6]. It Bhubaneswar, Odisha, India is relatively rare in post-operative endophthalmitis (2.4–3.9%), as compared to traumatic endophthalmitis S. Sharma Jhaveri Microbiology Centre, L V Prasad Eye Institute, [4, 5]. Another study reported that 20.9% of polymi- KAR Campus, Hyderabad, Telangana, India crobial endophthalmitis were due to post-operative 123 2144 Int Ophthalmol (2019) 39:2143–2148 causes, while 72.1% were due to post-traumatic causes cases, where each microbiological isolate individually [3]. Polymicrobial infections generally lead to poorer influenced the clinical outcome of the disease. anatomical and visual prognosis compared to monomicrobial infections [6]. However, none of the Case reports previous reports have explored the unique clinical characteristics introduced by specific organisms iso- Case 1 A 71-year-old diabetic and hypertensive lated in polymicrobial infections. Herein, we report a female on irregular treatment presented with redness, series of three cases, in which two different organisms pain and watering in right eye, following an unevent- were isolated from ocular samples in post-operative ful manual small incision cataract surgery with endophthalmitis and investigate possible relationships intraocular lens (IOL) implantation in the same eye between these organisms and the clinical presentation 1 month ago. At presentation, her BCVA in right eye in each case. was finger count at 30 cm with 1-mm hypopyon and dense vitritis with hazy fundus view. We diagnosed delayed onset post-operative endophthalmitis in right Methods eye and treated her with vitreous biopsy and standard empirical intravitreal therapy (vancomycin, cef- We reviewed the microbiological reports of all tazidime and dexamethasone). Microbiological eval- patients with post-operative endophthalmitis between uation of vitreous biopsy showed gram-negative January and August 2017, where more than one bacilli on smear and significant growth of Burkholde- organism was isolated by standard microbiological ria cepacia on culture (Fig. 1a), which was resistant to techniques. Our laboratory protocol involved careful fluoroquinolones, macrolides, chloramphenicol and handling of samples to prevent any contamination colistin and sensitive only to ceftazidime, imipenem during inoculation, transport or incubation of media. and piperacillin–tazobactam. As patient’s condition All organisms were identified by standard biochemical did not improve after 5 intravitreal imipenem injec- tests and confirmed by VITEK 2 compact system. tions and high oral dose (750 mg) of ciprofloxacin, she Antibiotic susceptibility of organisms was done by underwent IOL explantation and vitreous debulking. Kirby–Bauer disc diffusion method and for colistin Though the aqueous and vitreous were sterile this specifically by broth microdilution test. Significant time, the IOL had a significant growth of a gram- growth in inoculated media was considered based on negative bacillus identified as Aeromonas veronii any 1 or more of the following 3 criteria: (a). growth of (Fig. 1b), which had exactly the same pattern of the same organism at the site of inoculation in 2 or antibiotic susceptibility as the B. cepacia isolated more media. (b). Growth of the same organism as seen earlier. The patient received repeated imipenem in the smear at the site of inoculation on a single injections and improved to a corrected vision of media. (c). Confluent growth of the organism at the 20/50 in her right eye with no recurrence till the last site of inoculation ([ 10 colonies) on a single media. follow-up at 6 months post-vitrectomy. All patients with clinical diagnosis of infective post- Case 2 A 16-year-old boy with right eye develop- operative endophthalmitis received standard therapy mental cataract operated by lens aspiration and IOL of vitreous biopsy with intravitreal vancomycin implantation presented for follow-up at 3 weeks, (1 mg/0.1 ml), ceftazidime (2.25 mg/0.1 ml) and dex- when one of his two corneoscleral sutures was amethasone (400 lg/0.1 ml). Further treatment was removed aseptically, while the other was mistakenly based on specific microbiology reports and clinical left behind. He presented a week later with decreased response to treatment. vision and corneal ulcer at the corneal end of the remaining suture, hypopyon and dense vitritis in the operated eye (Fig. 2a). He had no symptoms of any Results other systemic infections and reported head bath with tap water immediately after suture removal. He We found 7 patients (0.12%) with polymicrobial post- underwent corneal scraping, removal of the retained operative endophthalmitis out of 65 culture-positive suture, vitreous biopsy and standard intravitreal van- cases during the study period. Here in, we report 3 comycin, ceftazidime and dexamethasone. Corneal 123 Int Ophthalmol (2019) 39:2143–2148 2145 Fig. 1 a Significant growth of Burkholderia cepacia on vitreous biopsy in sheep blood agar. b Significant growth of Aeromonas veronii on IOL (intraocular lens) on sheep blood agar from the same patient Fig. 2 a External photograph, right eye, showing corneal post-cataract surgery. b Post-treatment (6 weeks) photograph of infiltration at site of left-behind suture (10’o clock) with features the same eye showing healing of corneal ulcer with scarring and of conjunctival congestion, hypopyon and dense vitritis, 1 week resolving features of endophthalmitis scraping showed significant growth of Streptococcus Case 3 A 21-year-old male patient underwent pneumoniae, sensitive to fluoroquinolones, van- anterior vitrectomy and pars plana membranectomy comycin and cefazolin. In contrast, vitreous grew for thick posterior capsular opacification in right eye Sphingomonas paucimobilis, sensitive to aminogly- (Fig. 3b). Past records showed that he had a BCVA of cosides, fluoroquinolones, imipenem and colistin and 20/20, N6 2 years ago, in both eyes. He had been resistant to chloramphenicol, ceftazidime and piper- diagnosed before as Steven–Johnson syndrome with acillin–tazobactam. Patient was treated with oral dry eye, distichiasis and trichiasis in the right eye for ciprofloxacin, topical moxifloxacin and prednisolone which he received repeated epilations and intermittent acetate eye drops. The corneal ulcer healed with treatment with topical steroids and antibiotics scarring, vitritis resolved and BCVA improved to (Fig. 3a). On the third day, post-membranectomy, he 20/60 in right eye without any recurrence till the last presented with sudden reduction in vision to counting follow-up at 6 months (Fig. 2b). fingers at 2 m, hypopyon and dense vitreous exudates in the operated eye (Fig. 3a). With a diagnosis of acute 123 2146 Int Ophthalmol (2019) 39:2143–2148 Fig. 3 a External photograph, right eye, at presentation, showing corneal clearing, and resolution of vitreous exudates. showing distichiasis of upper and lower lid margins, diffuse c Significant growth of Enterococcus faecalis from vitreous conjunctival congestion, limbal naevus, diffuse corneal oedema, biopsy
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