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Anaerobic Streptococcal Corneal Ulcer
NOTES, CASES, INSTRUMENTS ANAEROBIC STREPTOCOCCAL CORNEAL ULCER
cornea. There was a small overlying epithelial de fect (Fig. 1). The anterior chamber showed 2 + cells and 1+ flare. Corneal sensation was normal. In the hospital we treated the eye with 5% erythH. B. OSTLER, M.D., AND M. OKUMOTO, M.A. romycin ophthalmic ointment every hour during San Francisco, California the day and every two hours at night; the 1% atropine ophthalmic drops were continued, and 50 Central corneal ulcers due to anaerobic mg of methicillin sodium was given subconjuncorganisms are rare. We found only one pub tivally. The cornea gradually cleared and the same lished case report 1 in the last ten years ; the medications were continued. The patient received a total of three subconjunctival injections of methi etiologic agent was referred to as "strepto- cillin over a four-day period. She was discharged thrix" (an old term for the actinomycotic after five days, all medication was discontinued organisms) and no details of the appearance after ten days, and she made an uneventful re covery (Fig. 2). By the tenth day the vision of of the organism or of the cornea were given. the injured eye had returned to 20/25. Not a single case of ulcer caused by anaerobic RESULTS streptococci was uncovered, and it seems that all of the anaerobic cases reported thus far At the initial examination, we took scrap have been due to either an actinomycotic2 or ings from the lesion for cytologie examina a clostridial organism.3 Recently, however, tion and for culture study on sheep's blood we observed and treated successfully an agar, cooked meat medium, and Sabouraud's anaerobic streptococcal corneal ulcer that agar (Emmons' modification). Cooked meat occurred in a healthy young girl after a medium was originally developed for the corneal injury. isolation of wound organisms and is rec CASE REPORT
We examined a 10-year-old white girl three days after she was struck in the left eye with a holly leaf. The first day after the injury she had been seen by her ophthalmologist because of pain and photophobia. The ophthalmologist found a corneal laceration that extended to Descemet's membrane, and he treated the eye with topically applied atro pine, twice daily, and with 10% sulfacetamide every waking hour the first day and every two hours the second day. On day 3 he referred the child to us and she was admitted to our hospital. According to her history, the patient was in good health and had not been taking any other medica tion. Her visual acuity was R.E. : 20/20, and L.E. : 20/70-1, which did not improve with a pinhole. The positive findings were limited to the cornea and anterior chamber of the injured eye. The cornea showed a paracentral infiltrate that surrounded the laceration and extended to the level of Descemet's membrane and was more marked deep within the From the Francis I. Proctor Foundation for Re search in Ophthalmology and the Department of Ophthalmology, University of California, San Fran cisco. This study was supported in part by grant 1 TO 1 EY-00094, National Institutes of Health. Reprint requests to H. B. Ostler, M.D., Francis I. Proctor Foundation, University of California at San Francisco, San Francisco, CA 94143.
ommended for the cultivation of both anaer obic and aerobic bacteria. The blood agar and cooked meat medium were incubated at 37°C, the Sabouraud's agar at 30°C. No organisms were seen in Gram-stained preparations of the first scrapings, but re peated scrapings taken from a level at some depth within the lesion showed Gram-positive cocci suggesting staphylococci.
Fig. 1 (Ostler and Okumoto). Anaerobic strep tococcal corneal ulcer three days after initial in jury.
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NOTES, CASES, INSTRUMENTS
VOL. 81, NO. 4
Fig. 2 (Ostler and Okumoto). Anaerobic streptococcal corneal ulcer 13 days after initial injury.
Only the scrapings growing at some depth within the cooked meat medium showed evi dence of bacterial growth. Two days after the cultures were inoculated, a smear of this deeply growing material revealed tiny Grampositive bodies in chains of six or more spherical, evenly matched cocci typical of streptococci. Subcultures on aerobic media showed no evidence of growth, and cultures for fungi on Sabouraud's agar were negative. DISCUSSION
Anaerobic streptococci have been isolated from suppurative or gangrenous lesions and are a frequent source of severe puerperal sepsis and septicemia. These organisms are currently classified as members of the genus Peptostreptococcus, of which there are five species.4 The organisms are often small but may vary in size on subculture.8 They are usually sensitive to penicillin, of which the minimal inhibitory concentration ranges from 0.1 to 10.0 units/ml. 4 Liquid culture media enhance the chaining propensity of streptococci, as was evident to us by the chains observed in a vitreous smear from an unreported case of anaerobic streptococcal endophthalmitis. But in our experi ence with all streptococcal corneal infections, chain formation has been minimal in corneal
519
scrapings examined directly; short chains have been found only in preparations con taining relatively large numbers of organ isms. Reliance on direct examination of cor neal material has thus often led to confusion between staphylococci, streptococci, and pneumococci. In our patient, there were no identifying clinical signs, although the location of the abscess deep within the stroma, and the depth of the initial injury, certainly favored the possibility that an anaerobic organism was concerned. In addition, the initial, superficial scrapings showed no organisms, and it was only after material was removed from deep within the cornea that any organisms could be seen was suggestive of an anaerobic organ ism. The· rapid recovery indicated the organism was highly susceptible to the antibiotics used, and that the patient's immune mechanisms were functioning adequately. SUMMARY
An anaerobic streptococcus caused a cen tral corneal ulcer in a 10-year-old girl. There were no identifying clinical findings. The lesion healed promptly and satisfactorily with antibiotic therapy. ACKNOWLEDGMENT
Darrel F. Smith, M.D., referred this patient. REFERENCES
1. Smith, E. L., and Rose, H. A. : Medical and surgical management of deep central corneal ulcers and descemetoceles. Can. J. Ophthalmol. 2:115, 1967. 2. Gingrich, W. D., and Pinkerton, M. E. : An aerobic actinomycosis bovis corneal ulcer. Arch. Ophthalmol. 67:549, 1962. 3. Tsutsui, J. : Tetanus infection of cornea. Am. J. Ophthalmol. 43:772, 1957. 4. Buchanan, R. E., and Gibbons, N. E.: Bergey's Manual of Determinative Bacteriology, 8th ed. Baltimore, Williams and Wilkins, 1974, pp. 522525. 5. Wilson, G. S., and Miles, A. A. : Topley and Wilson's Principles of Bacteriology and Immunity, 5th ed. London, Edward Arnold, Ltd., 1964, vol. 1, p. 732.
cornea. There was a small overlying epithelial de fect (Fig. 1). The anterior chamber showed 2 + cells and 1+ flare. Corneal sensation was normal. In the hospital we treated the eye with 5% erythH. B. OSTLER, M.D., AND M. OKUMOTO, M.A. romycin ophthalmic ointment every hour during San Francisco, California the day and every two hours at night; the 1% atropine ophthalmic drops were continued, and 50 Central corneal ulcers due to anaerobic mg of methicillin sodium was given subconjuncorganisms are rare. We found only one pub tivally. The cornea gradually cleared and the same lished case report 1 in the last ten years ; the medications were continued. The patient received a total of three subconjunctival injections of methi etiologic agent was referred to as "strepto- cillin over a four-day period. She was discharged thrix" (an old term for the actinomycotic after five days, all medication was discontinued organisms) and no details of the appearance after ten days, and she made an uneventful re covery (Fig. 2). By the tenth day the vision of of the organism or of the cornea were given. the injured eye had returned to 20/25. Not a single case of ulcer caused by anaerobic RESULTS streptococci was uncovered, and it seems that all of the anaerobic cases reported thus far At the initial examination, we took scrap have been due to either an actinomycotic2 or ings from the lesion for cytologie examina a clostridial organism.3 Recently, however, tion and for culture study on sheep's blood we observed and treated successfully an agar, cooked meat medium, and Sabouraud's anaerobic streptococcal corneal ulcer that agar (Emmons' modification). Cooked meat occurred in a healthy young girl after a medium was originally developed for the corneal injury. isolation of wound organisms and is rec CASE REPORT
We examined a 10-year-old white girl three days after she was struck in the left eye with a holly leaf. The first day after the injury she had been seen by her ophthalmologist because of pain and photophobia. The ophthalmologist found a corneal laceration that extended to Descemet's membrane, and he treated the eye with topically applied atro pine, twice daily, and with 10% sulfacetamide every waking hour the first day and every two hours the second day. On day 3 he referred the child to us and she was admitted to our hospital. According to her history, the patient was in good health and had not been taking any other medica tion. Her visual acuity was R.E. : 20/20, and L.E. : 20/70-1, which did not improve with a pinhole. The positive findings were limited to the cornea and anterior chamber of the injured eye. The cornea showed a paracentral infiltrate that surrounded the laceration and extended to the level of Descemet's membrane and was more marked deep within the From the Francis I. Proctor Foundation for Re search in Ophthalmology and the Department of Ophthalmology, University of California, San Fran cisco. This study was supported in part by grant 1 TO 1 EY-00094, National Institutes of Health. Reprint requests to H. B. Ostler, M.D., Francis I. Proctor Foundation, University of California at San Francisco, San Francisco, CA 94143.
ommended for the cultivation of both anaer obic and aerobic bacteria. The blood agar and cooked meat medium were incubated at 37°C, the Sabouraud's agar at 30°C. No organisms were seen in Gram-stained preparations of the first scrapings, but re peated scrapings taken from a level at some depth within the lesion showed Gram-positive cocci suggesting staphylococci.
Fig. 1 (Ostler and Okumoto). Anaerobic strep tococcal corneal ulcer three days after initial in jury.
518
NOTES, CASES, INSTRUMENTS
VOL. 81, NO. 4
Fig. 2 (Ostler and Okumoto). Anaerobic streptococcal corneal ulcer 13 days after initial injury.
Only the scrapings growing at some depth within the cooked meat medium showed evi dence of bacterial growth. Two days after the cultures were inoculated, a smear of this deeply growing material revealed tiny Grampositive bodies in chains of six or more spherical, evenly matched cocci typical of streptococci. Subcultures on aerobic media showed no evidence of growth, and cultures for fungi on Sabouraud's agar were negative. DISCUSSION
Anaerobic streptococci have been isolated from suppurative or gangrenous lesions and are a frequent source of severe puerperal sepsis and septicemia. These organisms are currently classified as members of the genus Peptostreptococcus, of which there are five species.4 The organisms are often small but may vary in size on subculture.8 They are usually sensitive to penicillin, of which the minimal inhibitory concentration ranges from 0.1 to 10.0 units/ml. 4 Liquid culture media enhance the chaining propensity of streptococci, as was evident to us by the chains observed in a vitreous smear from an unreported case of anaerobic streptococcal endophthalmitis. But in our experi ence with all streptococcal corneal infections, chain formation has been minimal in corneal
519
scrapings examined directly; short chains have been found only in preparations con taining relatively large numbers of organ isms. Reliance on direct examination of cor neal material has thus often led to confusion between staphylococci, streptococci, and pneumococci. In our patient, there were no identifying clinical signs, although the location of the abscess deep within the stroma, and the depth of the initial injury, certainly favored the possibility that an anaerobic organism was concerned. In addition, the initial, superficial scrapings showed no organisms, and it was only after material was removed from deep within the cornea that any organisms could be seen was suggestive of an anaerobic organ ism. The· rapid recovery indicated the organism was highly susceptible to the antibiotics used, and that the patient's immune mechanisms were functioning adequately. SUMMARY
An anaerobic streptococcus caused a cen tral corneal ulcer in a 10-year-old girl. There were no identifying clinical findings. The lesion healed promptly and satisfactorily with antibiotic therapy. ACKNOWLEDGMENT
Darrel F. Smith, M.D., referred this patient. REFERENCES
1. Smith, E. L., and Rose, H. A. : Medical and surgical management of deep central corneal ulcers and descemetoceles. Can. J. Ophthalmol. 2:115, 1967. 2. Gingrich, W. D., and Pinkerton, M. E. : An aerobic actinomycosis bovis corneal ulcer. Arch. Ophthalmol. 67:549, 1962. 3. Tsutsui, J. : Tetanus infection of cornea. Am. J. Ophthalmol. 43:772, 1957. 4. Buchanan, R. E., and Gibbons, N. E.: Bergey's Manual of Determinative Bacteriology, 8th ed. Baltimore, Williams and Wilkins, 1974, pp. 522525. 5. Wilson, G. S., and Miles, A. A. : Topley and Wilson's Principles of Bacteriology and Immunity, 5th ed. London, Edward Arnold, Ltd., 1964, vol. 1, p. 732.