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Bacillus Licheniformis Corneal Ulcer
NOTES, CASES AND INSTRUMENTS PEDIATRIC OCULAR PHOTOGRAPHY PLATFORM M I C H A E L W. F O X W O R T H ,
B.S.,
AND R. M I C H A E L N I S B E T , Galveston,
M.D.
Texas
To take advantage of the Zeiss camera system, we designed a platform to sup port infants or small animals while photo graphing the anterior segment or fundus (Figs. 1 and 2), or during fluorescein angiography. The platform is a 15 X 30-inch rectan gle of white lucite plastic positioned at a level 18.75 inches from the base of the camera table. It is mounted in a rigid frame of reinforced aluminum attached to two pins that fit into the receptacle nor mally used to support the chin rest of the Zeiss fundus camera. The platform is inset four inches from the lower vertical
Fig. 2 (Foxworth and Nisbet). Pediatric photogra phy platform attached to Zeiss fundus camera.
support to provide adequate working dis tance and full use of the joystick controls. SUMMARY
We designed a rigid support platform to facilitate ocular photography of infants or small animals. The platform is versatile because it is compatible with either the Zeiss fundus camera or Zeiss Photo Slit Lamp. BACILLUS LICHENIFORMIS CORNEAL ULCER K H A L I D F. TABBARA,
M.D.,
AND N A B I L TARABAY, Beirut,
M.D.
Lebanon
Bacillus organisms, except for B. anthracis, are generally regarded as saproFig. 1 (Foxworth and Nisbet). Pediatric photogra phy platform attached to Zeiss Photo Slit Lamp. From the Department of Ophthalmology, Univer sity of Texas Medical Branch, Galveston, Texas. Reprint requests to R. Michael Nisbet, M.D., Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX 77550.
From the Department of Ophthalmology, Ameri can University Medical Center, Beirut, Lebanon. This study was supported in part by Grant No. 18-5116 from the School of Medicine, American University of Beirut, Beirut, Lebanon. Reprint requests to Khalid F. Tabbara, M.D., Francis I. Proctor Foundation, 315-S, University of California, San Francisco, CA 94143.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1979
phytes but can become pathogenic if the host's local or systemic defense mecha nisms are altered. A number of species of the genus Bacillus have caused various ocular infections but rarely cause corneal ulcers. We describe herein a case of cor neal ulcer caused by B. licheniformis. CASE REPORT A 46-year-old woman had pain, redness, and swelling of the right eye for 20 days. She said that the eye had been slightly injured by a twig two days before the onset of her symptoms. On examination visual acuity was light perception in the right eye. Moderate swelling of the right upper eyelid was evident, the bulbar conjunctiva was injected and edematous, and there was a subconjunctival hemorrhage interiorly. The cornea had a central ulcer with marked corneal necrosis and infiltration, and a 2-mm zone of clear cornea superi orly (Fig. 1). The anterior chamber contained a fibrin clot. The lens and fundus could not be visua lized. The left eye showed no abnormalities. X-ray of the right orbit showed no evidence of an intraocu lar foreign body. Scrapings from the ulcer, gram- and Giemsastained, contained gram-positive rods. Cultures of the scrapings showed a heavy growth of aerobic, spore-forming, gram-positive bacilli that were iden tified, on the basis of their biochemical reactions, as B. licheniformis1 Table). The organism was sensi tive to gentamicin sulfate, tetracycline, lincomycin hydrochloride, cephalothin sodium, cephradin, rifamycin, and trimethoprimsulfamethoxazole; it was resistant to penicillin G, erythromicin, ampicillin, and methicillin sodium. The patient was given subconjunctival injections of gentamicin and staphcillin. After the antibiogram, we started a regimen of topical, subconjuncti val, and intramuscular gentamicin sulfate. Improve ment began on day 5; three weeks later the corneal ulcer had resolved and healing was underway (Fig. 2).
Fig. 1 (Tabbara and Tarabay). Extensive necrosis' of the cornea in a patient with B. licheniformis corneal ulcer.
Fig. 2 (Tabbara and Tarabay). The same eye three weeks after treatment was begun.
DISCUSSION
Organisms of the genus Bacillus are aerobic, spore-forming, gram-positive rods. They are found commonly in air, soil, dust, hay, milk, water, and wool. With the exception of B. anthracis, they are usually nonpathogenic for man; how ever, exceptions exist. They have caused systemic diseases such as meningitis, pneumonia, and sepsis 2 (in both debilitat ed hosts and apparently normal hosts) and have been reported as causes of cor neal ulcers 3 and endophthalmitis 4 after trauma or surgery. Because organisms of this genus are regarded as relatively insig nificant; and their taxonomic relation ships are complex and controversial, most clinical laboratories report any member of the Bacillus group as B. subtilis or "hay bacillus." Several species of the Bacillus group recovered from eye infections have been identified as causative; for example, B. laterosporus,5 B. cereus,e and B. subtilis.7 Although B. licheniformis has been re ported as a cause of sepsis in a patient with no known immunologic defect, to the best of our knowledge, the species has not previously been reported as a cause of ocular infection. Our patient had no de bilitating disease or immune deficiency, but her injury may have disrupted the cornea's first line of defense, that is, its anatomic integrity. Minor corneal trau-
TABLE C R I T E R I A F O R I D E N T I F I C A T I O N O F BACILLUS
LICHENIFORMIS
Test
Result Long, thin, gram+, variably sized rod with subterminal spores Equal Positive Positive Beta hemolysis Alkaline Positive Positive Negative Positive Negative Positive Negative Negative Positive Basic/Acid
Gram stain Growth at 37 and 50°C Motility Anaerobic growth Hemolysis on rabbit blood agar 10% lactose Catalase Oxidase Salmonella-Shigella medium Citrate Urea Nitrate Indol Methyl red Voges-Proskauer Triple sugar iron (TSI) agar (slant/butt) Hydrogen sulfide production Gelatin Litmus milk Nutrient broth: 0% N a C l 6% N a C l 7% N a C l Starch hydrolysis Glucose D-xylose Mannitol Lactose Sucrose Maltose
Negative Partially positive at 7 days Negative Positive Positive Positive Positive Acid Acid Acid and gas No change Acid Acid
ma of this kind is believed to predispose to corneal infection. SUMMARY
A 46-year-old woman developed a cor neal ulcer after an injury to the right eye. Cultures were positive for Bacillus lich eniformis. Although resistant to some an tibiotics, the corneal ulcer resolved after treatment with topical, subconjunctival, and intramuscular gentamicin sulfate.
5. Tabbara, K. F., Juffali, F., and Matossian, R. M.: Bacillus laterosporus endophthalmitis. Arch. Ophthalmol. 95:2187, 1977. 6. Farrar, W. E.: Serious infections due to "nonpathogenic" organisms of the genus Bacillus. Am. J. Med. 34:134, 1963. 7. Pearson, H. E.: Human infections caused by organisms of the Bacillus species. Am. J. Clin. Pathol. 53:506, 1970.
BICONCAVE CONTACT LENS FOR VITREOUS SURGERY
REFERENCES
J O H N G. S E B E S T Y E N , M.
1. Sugar, A. M., and McCloskey, R. V.: Bacillus licheniformis sepsis. J.A.M.A. 238:1180, 1977. 2. Ihde, D. C , and Armstrong, D. A.: Clinical spectrum of infection due to Bacillus species. Am. J. Med. 55:839, 1973. 3. Van Bijsterveld, O. P., and Richards, R. D.: Bacillus infections of the cornea. Arch. Ophthalmol. 74:91, 1965. 4. Davenport, R., and Smith, C.: Panophthalmitis due to an organism of the Bacillus subtilis group. Br. J. Ophthalmol. 36:389, 1952.
Boston,
D.
Massachusetts
During trans pars plana vitreous surgi cal procedures adequate visualization of From the Wm. P. Beetham Eye Unit, Joslin Clin ic, Joslin Diabetic Foundation, Boston, Massachu setts. Reprint requests to John G. Sebestyen, M.D., One Joslin Place, Boston, MA 02215.
719
B.S.,
AND R. M I C H A E L N I S B E T , Galveston,
M.D.
Texas
To take advantage of the Zeiss camera system, we designed a platform to sup port infants or small animals while photo graphing the anterior segment or fundus (Figs. 1 and 2), or during fluorescein angiography. The platform is a 15 X 30-inch rectan gle of white lucite plastic positioned at a level 18.75 inches from the base of the camera table. It is mounted in a rigid frame of reinforced aluminum attached to two pins that fit into the receptacle nor mally used to support the chin rest of the Zeiss fundus camera. The platform is inset four inches from the lower vertical
Fig. 2 (Foxworth and Nisbet). Pediatric photogra phy platform attached to Zeiss fundus camera.
support to provide adequate working dis tance and full use of the joystick controls. SUMMARY
We designed a rigid support platform to facilitate ocular photography of infants or small animals. The platform is versatile because it is compatible with either the Zeiss fundus camera or Zeiss Photo Slit Lamp. BACILLUS LICHENIFORMIS CORNEAL ULCER K H A L I D F. TABBARA,
M.D.,
AND N A B I L TARABAY, Beirut,
M.D.
Lebanon
Bacillus organisms, except for B. anthracis, are generally regarded as saproFig. 1 (Foxworth and Nisbet). Pediatric photogra phy platform attached to Zeiss Photo Slit Lamp. From the Department of Ophthalmology, Univer sity of Texas Medical Branch, Galveston, Texas. Reprint requests to R. Michael Nisbet, M.D., Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX 77550.
From the Department of Ophthalmology, Ameri can University Medical Center, Beirut, Lebanon. This study was supported in part by Grant No. 18-5116 from the School of Medicine, American University of Beirut, Beirut, Lebanon. Reprint requests to Khalid F. Tabbara, M.D., Francis I. Proctor Foundation, 315-S, University of California, San Francisco, CA 94143.
717
718
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1979
phytes but can become pathogenic if the host's local or systemic defense mecha nisms are altered. A number of species of the genus Bacillus have caused various ocular infections but rarely cause corneal ulcers. We describe herein a case of cor neal ulcer caused by B. licheniformis. CASE REPORT A 46-year-old woman had pain, redness, and swelling of the right eye for 20 days. She said that the eye had been slightly injured by a twig two days before the onset of her symptoms. On examination visual acuity was light perception in the right eye. Moderate swelling of the right upper eyelid was evident, the bulbar conjunctiva was injected and edematous, and there was a subconjunctival hemorrhage interiorly. The cornea had a central ulcer with marked corneal necrosis and infiltration, and a 2-mm zone of clear cornea superi orly (Fig. 1). The anterior chamber contained a fibrin clot. The lens and fundus could not be visua lized. The left eye showed no abnormalities. X-ray of the right orbit showed no evidence of an intraocu lar foreign body. Scrapings from the ulcer, gram- and Giemsastained, contained gram-positive rods. Cultures of the scrapings showed a heavy growth of aerobic, spore-forming, gram-positive bacilli that were iden tified, on the basis of their biochemical reactions, as B. licheniformis1 Table). The organism was sensi tive to gentamicin sulfate, tetracycline, lincomycin hydrochloride, cephalothin sodium, cephradin, rifamycin, and trimethoprimsulfamethoxazole; it was resistant to penicillin G, erythromicin, ampicillin, and methicillin sodium. The patient was given subconjunctival injections of gentamicin and staphcillin. After the antibiogram, we started a regimen of topical, subconjuncti val, and intramuscular gentamicin sulfate. Improve ment began on day 5; three weeks later the corneal ulcer had resolved and healing was underway (Fig. 2).
Fig. 1 (Tabbara and Tarabay). Extensive necrosis' of the cornea in a patient with B. licheniformis corneal ulcer.
Fig. 2 (Tabbara and Tarabay). The same eye three weeks after treatment was begun.
DISCUSSION
Organisms of the genus Bacillus are aerobic, spore-forming, gram-positive rods. They are found commonly in air, soil, dust, hay, milk, water, and wool. With the exception of B. anthracis, they are usually nonpathogenic for man; how ever, exceptions exist. They have caused systemic diseases such as meningitis, pneumonia, and sepsis 2 (in both debilitat ed hosts and apparently normal hosts) and have been reported as causes of cor neal ulcers 3 and endophthalmitis 4 after trauma or surgery. Because organisms of this genus are regarded as relatively insig nificant; and their taxonomic relation ships are complex and controversial, most clinical laboratories report any member of the Bacillus group as B. subtilis or "hay bacillus." Several species of the Bacillus group recovered from eye infections have been identified as causative; for example, B. laterosporus,5 B. cereus,e and B. subtilis.7 Although B. licheniformis has been re ported as a cause of sepsis in a patient with no known immunologic defect, to the best of our knowledge, the species has not previously been reported as a cause of ocular infection. Our patient had no de bilitating disease or immune deficiency, but her injury may have disrupted the cornea's first line of defense, that is, its anatomic integrity. Minor corneal trau-
TABLE C R I T E R I A F O R I D E N T I F I C A T I O N O F BACILLUS
LICHENIFORMIS
Test
Result Long, thin, gram+, variably sized rod with subterminal spores Equal Positive Positive Beta hemolysis Alkaline Positive Positive Negative Positive Negative Positive Negative Negative Positive Basic/Acid
Gram stain Growth at 37 and 50°C Motility Anaerobic growth Hemolysis on rabbit blood agar 10% lactose Catalase Oxidase Salmonella-Shigella medium Citrate Urea Nitrate Indol Methyl red Voges-Proskauer Triple sugar iron (TSI) agar (slant/butt) Hydrogen sulfide production Gelatin Litmus milk Nutrient broth: 0% N a C l 6% N a C l 7% N a C l Starch hydrolysis Glucose D-xylose Mannitol Lactose Sucrose Maltose
Negative Partially positive at 7 days Negative Positive Positive Positive Positive Acid Acid Acid and gas No change Acid Acid
ma of this kind is believed to predispose to corneal infection. SUMMARY
A 46-year-old woman developed a cor neal ulcer after an injury to the right eye. Cultures were positive for Bacillus lich eniformis. Although resistant to some an tibiotics, the corneal ulcer resolved after treatment with topical, subconjunctival, and intramuscular gentamicin sulfate.
5. Tabbara, K. F., Juffali, F., and Matossian, R. M.: Bacillus laterosporus endophthalmitis. Arch. Ophthalmol. 95:2187, 1977. 6. Farrar, W. E.: Serious infections due to "nonpathogenic" organisms of the genus Bacillus. Am. J. Med. 34:134, 1963. 7. Pearson, H. E.: Human infections caused by organisms of the Bacillus species. Am. J. Clin. Pathol. 53:506, 1970.
BICONCAVE CONTACT LENS FOR VITREOUS SURGERY
REFERENCES
J O H N G. S E B E S T Y E N , M.
1. Sugar, A. M., and McCloskey, R. V.: Bacillus licheniformis sepsis. J.A.M.A. 238:1180, 1977. 2. Ihde, D. C , and Armstrong, D. A.: Clinical spectrum of infection due to Bacillus species. Am. J. Med. 55:839, 1973. 3. Van Bijsterveld, O. P., and Richards, R. D.: Bacillus infections of the cornea. Arch. Ophthalmol. 74:91, 1965. 4. Davenport, R., and Smith, C.: Panophthalmitis due to an organism of the Bacillus subtilis group. Br. J. Ophthalmol. 36:389, 1952.
Boston,
D.
Massachusetts
During trans pars plana vitreous surgi cal procedures adequate visualization of From the Wm. P. Beetham Eye Unit, Joslin Clin ic, Joslin Diabetic Foundation, Boston, Massachu setts. Reprint requests to John G. Sebestyen, M.D., One Joslin Place, Boston, MA 02215.
719