Infectious Disease Reports 2016; volume 8:6320 First report of acute This complication often occurs sporadically, and in such situations, the common source of Correspondence: Enrique Rodríguez de la Rúa, postoperative endophthalmitis infection may be due to the conjunctival flora UGC Oftalmología, Hospital Universitario Virgen caused by Rothia mucilaginosa of the patient. The major pathogens are coagu- Macarena, AV/Fedriani sn, 41010 Sevilla, Spain. after phacoemulsification lase-negative staphylococci (70%), Tel.: +34.606.461164. Staphylococcus aureus (10%), streptococci E-mail: [email protected] Pablo Álvarez-Ramos,1 (9%), other Gram-positive cocci, including enterococci and mixed bacteria (5%), and Key words: Rothia mucilaginosa; endophthalmi- Amparo Del Moral-Ariza,1 tis; phacoemulsification; cataract; biofilm; Gram-negative bacilli (6%). The fact that José M. Alonso-Maroto,1 intraocular lens. Gram-positive bacteria cause >95% of the Pilar Marín-Casanova,2 cases reflect the usual pathogenesis, i.e. con- José M. Calandria-Amigueti,1 Acknowledgements: the Universitario Virgen tamination of the aqueous humor with skin Macarena Hospital is a clinical associated center Manuel Rodríguez-Iglesias,2 bacteria flora during surgery.1 However, of the Network: RETICS RD12/0034 1,3 Enrique Rodríguez de la Rúa unusual germs causing the infection are Enfermedades Oculares. “Prevención, detección 1Ophthalmology Unit, University Hospital sometimes isolated and should be suspected in precoz y tratamiento de la patología ocular preva- Puerta del Mar, Cádiz; 2Microbiology Unit, cases with a non-typical evolution. lente degenerativa y crónica”. Oftared. Instituto de Salud Carlos III. Spain. University Hospital Puerta del Mar, Cádiz; 3 Ophthalmology Unit, University Contributions: PAV obtained the data, performed Hospitals Virgen Macarena y Virgen del Case Report a literature review, and drafted the manuscript; Rocío, Sevilla, Spain JAM, AMA, JCA and ERR managed the case and revised the manuscript critically; MRI and PMC A 65 year-old female patient was urgently performed the microbiological analysis and criti- admitted to a hospital emergency room 48 cally revised the article. hours after a cataract surgery, referring to red Abstract eye and vision decrease in the operated eye. Conflict of interest: the authors declare no poten- Visual acuity on the initial exam was hands tial conflictonly of interest. We aimed at reporting the first case of rap- movement in the right eye and 20/40 in the left idly progressive acute postoperative endoph- eye. A hydrophobic acrylic aspheric intraocular Received for publication: 24 November 2015. thalmitis after phacoemulsification cataract lens was used. Ophthalmological examinations Revision received: 12 January 2016. Accepted for publication: 25 January 2016. surgery in an immunocompetent patient showed conjunctival injection in the rightuse eye, caused by Rothia mucilaginosa. An immuno- hypopyon, 3+ cells in anterior chamber and This work is licensed under a Creative Commons competent patient manifested endophthalmi- severe vitreitis with no fundus view. Acute Attribution-NonCommercial 4.0 International tis signs 48 hours after an uncomplicated post-cataract endophthalmitis was suspected. License (CC BY-NC 4.0). cataract surgery by phacoemulsification. A She was hospitalized and 23G pars plana vit- bacteria of the family Micrococcaceae was cul- rectomy was immediately performed and a vit- ©Copyright P. Álvarez-Ramos et al., 2016 tured in the vitreous biopsy, namely R. reous biopsy was taken for culture. Licensee PAGEPress, Italy mucilaginosa. The patient did not show a Additionally, she was treated with topical ocu- Infectious Disease Reports 2016; 8:6320 doi:10.4081/idr.2016.6320 favorable clinical response after vitrectomy lar applications of fortified tobramycin (15 and systemic, intravitreal, and topical fortified mg/mL) and ceftazidime (50 mg/mL) every antibiotics. The patient’s eye was very painful, hour and with intravitreal injections of van- and consequently, it deemed necessary to per- comycin (1 mg/0.1 mL) and ceftazidime (2 ceptible to all antibiotics tested (penicillins, form an evisceration. R. mucilaginosa may be mg/0.1commercial mL) after the vitrectomy and 2 and 4 cephalosporins, fluoroquinolones, erythromy- an aggressive etiologic agent for postoperative days after operation. Intravenous antibiotics cin, clindamycin, and tetracycline). endophthalmitis. Although the isolated R. (1 g of vancomycin) were also administered Although this organism was susceptible to mucilaginosa was susceptible to empirical twice a day, 500 mg ceftazidime/12 hours, as the empirical antibiotics used, a bad clinical treatment, it was impossible to control the well as the administration of systemic corticos- response was observed with increasing infection with standard treatment, Nonprobably teroid after 24 hours (oral prednisone 1 hypopyon. During the next days, pain, conjunc- due to its ability to create a biofilm around the mg/kg/day). Because of the bad evolution after tival injection, hypopyon and anterior chamber intraocular lens. 36 hours, systemic treatment was then empir- reaction worsened and a large vitreous abscess ically changed to linezolid 600 mg and moxi- was observed. The patient had no light percep- floxacin 400 mg, twice a day. tion in the eye, which was very painful. Vitreous was cultured in blood agar, choco- Evisceration was consequently performed. Introduction late agar (incubated 48h in microaerophilic conditions) and thioglycollate broth; and was Cataract surgery is one of the most common isolated in an all media pure culture of Gram- eye operations performed worldwide. Although positive cocci, forming white colonies and Discussion cataract surgery is highly effective and rela- catalase positive, which was identified by the tively safe, owing to the enormous numbers, Microbiology Laboratory as Rothia mucilagi- R. mucilaginosa, formerly called even uncommon surgical complications could nosa through matrix-assisted laser desorp- Stomatococcus mucilaginosus, is part of the be potentially harmful for many patients.1 tion/ionization-time of flight (MALDI-TOF, normal flora of the upper respiratory tract and Endophthalmitis is one of the most serious Bruker Daltonics, Bruker Corporation, oral cavity. It was reclassified into a new genus complications of cataract surgery, affecting Billerica, MA, USA). Direct Gram stain was belonging to the family Micrococcaceae in around 0.1% of the cases, and often resulting negative. Antimicrobial sensitivity test was 2000,3 based on 16S rRNA sequencing. Gram in severe visual impairment.2 done by the Kirby-Bauer method, being sus- staining reveals non-spore-forming, encapsu- [page 6] [Infectious Disease Reports 2016; 8:6320] Case Report lated Gram-positive cocci that can appear in patient could be the origin of the infection, but 2. Cao H, Zhang L, Li L, Lo S. Risk factors for pairs, tetrads, or irregular clusters. It is a fac- contamination of eye drops used in the periop- acute endophthalmitis following cataract ultative anaerobic bacterium, which grows erative period with R. mucilaginosa is also a surgery: a systematic review and meta- well on most nonselective media and in stan- possibility. Unfortunately, a search of R. analysis. PLoS One 2013;8:e71731. dard blood culture systems. On sheep blood mucilaginosa in the eye drops was not per- 3. Collins MD, Hutson RA, Båverud V, Falsen and chocolate agar, the bacterium forms clear formed when the patient was admitted in the E. Characterization of a Rothia-like organ- to gray/white, non-hemolytic, mucoid or sticky hospital. It would have been of interest to ism from a mouse: description of Rothia colonies, which adhere to the agar surface. It demonstrate the origin of the contamination. nasimurium sp. nov. and reclassification can be difficult to distinguish it from coagu- However, it was reported that R. mucilaginosa of Stomatococcus mucilaginosus as Rothia lase-negative staphylococci, micrococci, and is able to colonize a foreign body as a vascular mucilaginosa comb. nov. Int J Syst Evol streptococci based on the catalase test result. catheter.9 The organism’s ability to produce a Microbiol 2000;50:1247-51. Its inability to grow in 6.5% sodium chloride biofilm, similar to other Gram-positive bacte- 4. Ruoff KL. Miscellaneous catalase-nega- and its ability to hydrolyze gelatin and esculin ria, is believed to be a key pathogenic mecha- tive, gram-positive cocci: emerging oppor- distinguish it from species of Staphylococcus, nism. The physical protective layer provided by tunists. J Clin Microbiol 2002;40:1129-33. Micrococcus, and Enterococcus genera.4 the biofilm presumably facilitates adhesion of 5. Ramos JM, Mateo I, Rosillo EM, et al. Identification from automatic methods should the organisms to devices and renders them rel- Infection due to Rothia mucilaginosa. A correlate with phenotypic identification; other- atively refractory to medical therapy. Antibiotic respiratory pathogen? Enferm Infecc wise, genetic sequencing may be required to therapy alone is usually ineffective without Microbiol Clin 2014;32:306-9. identify this organism. It is an infrequent surgical removal of the infected device. This 6. Baeza Martínez C, Zamora Molina L, pathogen, mostly affecting immunocompro- could better support the failure of antibiotic García Sevila R, et al. Rothia mucilaginosa mized hosts. Recently, infections in immuno- treatment. Pneumonia in an immunocompetent competent hosts have been described in vari-