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Corneal Ulcer Due to Achromobacterxylosoxidans

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Corneal Ulcer Due to Achromobacterxylosoxidans Br J Ophthalmol: first published as 10.1136/bjo.68.7.472 on 1 July 1984. Downloaded from British Journal of Ophthalmology, 1984, 68, 472-474 Corneal ulcer due to Achromobacter xylosoxidans PHILIP E. NEWMAN,' PATRICIA HIDER,2 GEORGE 0. WARING III,' E. 0. HILL,3 LOUIS A. WILSON,' AND THOMAS S. HARBIN' From the 'Department of Ophthalmology, -and the 3Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA, and 2Hynson, Westcott, Dunning, Baltimore, Maryland, USA SUMMARY We report a case of corneal ulcer caused by the opportunistic organism Achromobacter xylosoxidans which developed during chronic topical steroid treatment of an eye with neovascular glaucoma. A. xylosoxidans has probably been underreported as a cause of ocular infection because of confusion between this organism and other Gram-negative organisms, particularly pseudomonas. A. xylosoxidans is resistant to aminoglycosides and some cephalosporins but not carbenicillin. This difference in antibiotic sensitivity patterns between A. xylosoxidans and pseudomonas makes an accurate differentiation between the 2 organisms important. This case was successfully treated after substituting topical carbenicillin for topical gentamicin and amikacin. Achromobacter xylosoxidans is a Gram-negative Treatment was instituted with atropine 1% twice daily water-borne bacterium first described and named in and dexamethasone 0-1% 4 times daily, with 1971 by Yabuuchi and Ohyama,' who isolated the disappearance of pain and inflammation. organism from the purulent ear discharge of 7 Two months later he again developed severe pain patients. The first report of an ophthalmic infection in the right eye associated with an infiltrate in the was in 1977, when the organism was isolated from an central cornea and loss of25% ofthe overlying corneal infected orbit.2 It has also been isolated from spinal tissue without hypopyon. Superficial and deep vessels http://bjo.bmj.com/ fluid, blood, urine, and bronchial washings.3 The occupied the entire peripheral cornea. The corneal organism has been variously classified as a Mimea ulcer was cultured with a cotton tipped applicator and and later Acinetobacter. It is easily confused with later placed on chocolate and blood agar. Samples pseudomonas and other Gram-negative pathogens taken for Gram stain revealed polymorphonuclear but has a different antibiotic sensitivity profile. We leucocytes and slender Gram-negative rods, tenta- report here a patient with a corneal abscess due to tively diagnosed as pseudomonas. Initial therapy this organism. included topical gentamicin 5 mg/ml hourly, sub- on September 30, 2021 by guest. Protected copyright. conjunctival injection of gentamicin 20 mg, topical Case report carbenicillin 6 mg/ml hourly, and atropine 1%. The dexamethasone 0-1% which he had used for the A 34-year-old man was struck in the right eye by an previous 2 months was discontinued. A repeat sub- airgun pellet at age 12, the accident resulting in no conjunctival injection of gentamicin 20 mg was given light perception. The patient remained comfortable on the second day. The initial culture report identified until September 1979, when he developed severe the organism as a pseudomonas species resistant to pain in the right eye. Examination at that time gentamicin but sensitive to carbenicillin. revealed a normal left eye, a 40 prism dioptre right The corneal infiltrate progressed and he was exotropia, right circumcorneal vascular injection, admitted to the Emory University cornea service. diffuse epithelial and stromal corneal oedema, iris The right cornea contained a large superior para- neovascularisation, a 3 mm hyphaema, a dense central, propeller-shaped, yellow-white stromal cataract, and an intraocular pressure of 54 mmHg. infiltrate with an overlying epithelial defect and There was no light perception in the eye and a diffuse epithelial and stromal oedema. diagnosis of neovascular glaucoma was made. Scrapings obtained from the ulcer with a platinum were Correspondence to George 0. Waring 111, MD, The Emory Clinic, spatula plated directly on to blood, chocolate, Department of Ophthalmology, 1365 Clifton Road NE, Atlanta, Lowenstein-Jensen, and Sabouraud agars and into Georgia 30322, USA. thioglycolate broth. Gram stain of the scrapings 472 Br J Ophthalmol: first published as 10.1136/bjo.68.7.472 on 1 July 1984. Downloaded from Corneal ulcer due to Achromobacter xylosoxidans 473 showed numerous polymorphonuclear leucocytes with local immune defense mechanisms, enabling and Gram-negative rods. The patient was continued achromobacter to establish itself opportunistically. on topical atropine 1%; carbenicillin 6 mg/ml was A. xylosoxidans is an aerobic, oxidase-positive, increased to every 30 minutes; topical amikacin 25 Gram-negative rod.7 The specific growth character- mg/ml was added every 30 minutes. After 2 days on istics of our isolate are listed in Table 2. In 1939 A. this therapy the infiltrate and ulcer remained xylosoxidans was included in the class Mimeae, which unchanged. were a group of Gram-negative bacilli.8 Gilardi,9 The initial cultures taken by the referring oph- while studying the Mimeae, was able to identify 2 thalmologist and those taken at Emory grew new genera biochemically; Achromobacter anitratus Achromobacter xylosoxidans. A tube dilution anti- and A. Iwoffii. A. anitratus was reported as a causative biotic sensitivity test of minimum inhibitory concen- agent of conjunctivitis'0 in 1949 and of corneal trations demonstrated resistance to amikacin at 64 ulcers"I in 1968. The organisms are Gram-negative, Itg/ml and resistance to gentamicin at 32 [tg/ml but oxidase-negative, and now recognised as members of sensitivity to carbenicillin at 8 ,ug/ml. Since the abscess the Acinetobacter group. Achromobacter and the was clearing clinically, the topical amikacin and car- Alcaligenes genus resemble each other biochemically. benicillin were continued for 72 hours, then amikacin However, oxidative production of acid from glucose was discontinued. By the sixth hospital day the epi- and xylose excludes Achromobacter from the genus thelial defect was healed, and minimal corneal Alcaligenes, which is assaccharolytic. infiltrates remained. After discharge on tapered doses Pien and Higa 12 isolated from external ear drainage of carbenicillin for a one-week period the patient 9 strains of A. xylosoxidans that had previously been became asymptomatic, and the ocular inflammation reported by their laboratory as Pseudomonas species, disappeared. non-P. aeruginosa. The organisms they isolated were peritrichously flagellated, oxidase-positive, Gram- Discussion negative, as well as sensitive to carbenicillin, sulphonamide, and trimethaprim/sulphamethaxozole The paucity of reports of ophthalmic infection caused combination. The type and number of flagella and by Achromobacter xylosoxidans may reflect the characteristic antibiotic sensitivity pattern serve infrequent recognition of the organism caused by to differentiate Achromobacter from Pseudomonas, confusion in the nomenclature and difficulty in which is resistant to sulphonamide/trimethaprim/ identification. Because pseudomonas species are sulphamethaxozole.4 http://bjo.bmj.com/ common ocular pathogens, the misidentification of The source of A. xylosoxidans and its natural achromobacter as pseudomonas occurred in this case habitat are unknown. Holmes et al.2 suggested the when the early cultures indicated a Gram-negative organism is a water pathogen. Two of their strains rod. Consequently the patient was started immedi- were isolated from a swimming pool and from ately on gentamicin. This was an ineffective treat- chlorhexidine 05% solution. Shigeta et al. 13 ment, since achromobacter isolates are resistant to aminoglycosides and cephalosporins4 (Table 1). Table 1 antimicrobic susceptibilities ofAchromobacter on September 30, 2021 by guest. Protected copyright. Since A. xylosoxidans is most frequently found xylosoxidans from corneal ulcer accompanying other organisms in clinical infections,5 its pathogenic role is difficult to assess. It can be Antibiotic Broth minimum Agar disc considered an opportunistic pathogen. Dworzack et inhibitory concentra- diffusion al.6 described a patient with a deficiency of IgM who tion Rglml developed pneumonia due to A. xylosoxidans. Amikacin >64 R Holmes et al.2 reported finding A. xylosoxidans in the Ampicillin 16 R blood of one patient on chemotherapy for breast Carbenicillin 8 S in another Cefamandole 16 S carcinoma, patient with metastatic adeno- Cefoxitin >64 S carcinoma in the liver, and in a third patient on Cephalothin 64 R chronic steroid inhalation therapy. Chloroamphenicol 32 1 A. xylosoxidans has rarely been isolated from the Gentamycin >32 R eye. et Kenamycin >64 R Holmes al.2 isolated the organism from the Penicillin >16 R infected orbit of a patient who had lost the globe after PolymyxinB 8 S a perforating injury from shrapnel. Our case is Tetracycline 32 R unusual because the corneal ulcer was due solely to Tobramycin >32 R achromobacter. The patient was on chronic topical Trimethoprim/ steroids for therapy of his noevascular glaucoma and sulphamethoxazole 1-2/0-06 S corneal oedema. The steroids probably interfered R=resistant. S=sensitive. I=intermediate. Br J Ophthalmol: first published as 10.1136/bjo.68.7.472 on 1 July 1984. Downloaded from 474 Newman, Hider, Waring, Hill, Wilson, and Harbin Table 2 Biochemical characteristics ofAchromobacter encountered, because of its resistance to gentamicin xylosoxidans isolatefrom
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