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Corneal Ulcer Caused by Pasteurella Multocida
CORNEAL
ULCER CAUSED
PASTEURELLA
BY
MULTOCIDA
JOHN J . PURCELL, JR., M.D., AND J A Y H . K R A C H M E R ,
M.D.
Iowa City, Iowa
Pasteurella multocida (séptica), a known animal pathogen, which rarely infects the human eye, has been increasingly implicated in infections other than the eye during recent years, and is easily confused with Hemophilus influenza, Mima polymorpha, or Friedlanders pneumobacillus. T o our knowledge this is the first report of a documented case of human corneal ulceration caused by P. multocida. T h e organism was transferred to the abraded cornea of a rabbit and produced a similar ulcer and hypopyon. 1
CASE REPORT
Fig. 1 (Purcell and Krachmer). On admission, the patient's right eye has purulent discharge, injection and Chemosis, and corneal ulcer.
In November 1975, a 44-year-old woman had a one-week history of mild pain over the right eye and maxillary sinus, decreased vision, and eyelid swelling. Her right eye had been "bumped" by her pet dog two days before the onset of symptoms while she was teaching it back flips. There were no systemic symptoms. On admission, visual acuity was R.E.: light perception with projection, and L.E.: 6/9 (20/30). She was afebrile. Both eyes were proptotic. Hertel exophfhalmometer readings were R.E.: 29 and L . E . : 28 with a baseline of 105. Tenderness and swelling were present over the right maxillary sinus and her eyelids were red and swollen. The conjunctiva was diffusely injected and chemotic (Fig. 1) and an infected corneal ulcer with hypopyon involved the entire cornea with thinning nasally in a ring-shaped fashion. The conjunctiva had deposits of yellow tapioca-colored material temporally. The iris and remainder of the eye were barely visible. A tender right preauricular node was palpated. The left eye was proptotic but otherwise normal. The ulcer bed and margins were scraped with a spatula (Kimura). Gram and Giemsa stains as well as culture for aerobic and anaerobic bacteria, atypical mycobacteria, and fungi were performed. Gram
From the Department of Ophthalmology, University of Iowa College of Medicine, Iowa City, Iowa. Reprint requests to Jay H. Krachmer, M.D., C. S. O'Brien Library, Department of Ophthalmology, University Hospitals, Iowa City, IA 52242. 540
stain revealed gram-negative coccobacillary forms and gram-negative rods as well as many polymorphonuclear cells. Echography revealed no orbital masses, a normal vitreous body and retina, and thickening of the extraocular muscles of both eyes consistent with Graves' disease. Examination of the ear, nose, throat, and paranasal sinuses including radiologic evaluation was normal. The initial impression was exophthalmos secondary to Graves' disease, and corneal ulceration and hypopyon caused by a gram-negative organism. The patient was given 100 mg of methicillin and 20 mg of gentamicin subconjunctival^, every 12 hours for four days, and 500 mg of ampicillin by mouth, every six hours weekly. Fortified gentamicin eyedrops (8 mg/ml) and polymyxin B-neomycin-gramicidin eyedrops (Neosporin) were given every half hour around the clock for three days and then hourly for three more days. Atropine 1% and phenylephrine (Neo-Synephrine) 10% were instilled twice daily. Acetylcysteine 20% was instilled every four hours. Cultures revealed a heavy growth of a pleomorphic gram-negative organism on several media and fermentation and biochemical tests proved this to be P. multocida. By the fifth day the eye appeared quieter and the cornea was becoming reepithelialized. Prednisolone 1% was begun twice daily, and the antibiotic eyedrops were decreased to every two hours. The corticosteroid was increased to four times daily as the inflammation slowly decreased and epithelialization increased. The patient was discharged after 18 days with a persistent epithelial defect and an organized
PASTEURELLA
VOL. 83, NO. 4
MULTOCIDA
541
CORNEAL ULCER
hypopyon. Twelve days after discharge she had pain and a hyphema. She denied trauma. An epithelial defect was treated with pressure patching and it slowly epithelialized. The hyphema resolved. The eye is quiet with a corneal scar and cataract (Fig. 2). She is comfortable and visual acuity is counting lingers. To determine whether the organism isolated from the patient was capable of causing this corneal response, material from the infected cornea was inoculated onto the right cornea of a 2.074-g male Dutch rabbit after the epithelium had been abraded by a tuberculin syringe. The rabbit's fellow eye was abraded and inoculated with normal saline as a control. In three days a corneal ulcer developed on the right eye and by eight days a florid ulceration and hypopyon were present (Fig. 3). Culture, sensitivity studies, and biochemical tests of the organism from the rabbit corneal ulcer were identical to those of the patient and revealed P. multocida. DISCUSSION
Pasteurella multocida is a pleomorphic, gram-negative, non-motile coccobacillus with bipolar staining, and is in the normal flora of the upper respiratory system of many animals. In man, infection caused b y Pasteurella has been recorded in animal bites, meningitis, brain abscess, mastoiditis, sinusitis, pyogenic arthritis, bacteremia, bronchiectasis, appendiceal abscess, pneumonia, bronchiectasis, endocarditis, and pyelonephritis. T h e organism was isolated in the case of panophthalmitis secondary to a cat scratch. T w o cases of conjunctivitis, one of keratitis and one of proptosis from pansinusitis, were recorded in an epidemiologic study in the United States from 2
1
3
Fig. 3 (Purcell and Krachmer). Right eye of rabbit eight days after inoculation with scraping of patient's corneal ulcer.
1 9 6 5 through 1 9 6 8 . L i n d n e r reported four cases of corneal ulcer presumably caused by P. multocida, although he did not fulfill biochemical criteria for isolation of the organism. Conjunctivitis is rarely caused b y P. multocida, and few cases have been recorded. T h e inoculation on an abraded rabbit cornea and subsequent ulceration suggest that this organism is virulent toward the cornea if the epithelium is not intact. Since a variety of domestic and wild animals harbor this organism it should be suspected in all corneal ulcers with a history of animal contact. O n e does not have to be bitten but can acquire the organism from the saliva or respiratory discharge of animals. 4
5
6
4
SUMMARY
Fig. 2 (Purcell and Krachmer). Three months after admission, the corneal scar and thinning remain after the ulcer has healed.
A 44-year-old woman with Graves' disease and exophthalmos developed a severe corneal ulcer caused by Pasteurella multocida after being b u m p e d on her right eye by her pet dog. T h e organism was transferred from the patient to an
542
AMERICAN JOURNAL O F OPHTHALMOLOGY
abraded rabbit cornea and produced a similiar corneal ulcer and hypopyon. REFERENCES
1. Swartz, M. N., and Kunz, L. J . : Pasteurella multocida infections in man. N. Eng. J . Med. 261: 889, 1959. 2. De Boer, R. G., and Dumler, M.: Pasteurella multocida infections. Am. J . Clin. Pathol. 40:339, 1963.
APRIL, 1977
3. Galloway, N. R., and Robinson, G. E.: Panophthalmitis due to Pasteurella séptica. Br. J. Ophthalmol. 57:153, 1973. 4. Hubbert, W. T., and Rosen, M. N.: Pasteurella multocida infection in man unrelated to animal bite, Am. J. Publ. Health. 60:1109, 1970. 5. Lindner, K.: Ulcus Serpens fulminans. Z. Augenheilkd. 52:61, 1924. 6. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1964, p. 210.
ULCER CAUSED
PASTEURELLA
BY
MULTOCIDA
JOHN J . PURCELL, JR., M.D., AND J A Y H . K R A C H M E R ,
M.D.
Iowa City, Iowa
Pasteurella multocida (séptica), a known animal pathogen, which rarely infects the human eye, has been increasingly implicated in infections other than the eye during recent years, and is easily confused with Hemophilus influenza, Mima polymorpha, or Friedlanders pneumobacillus. T o our knowledge this is the first report of a documented case of human corneal ulceration caused by P. multocida. T h e organism was transferred to the abraded cornea of a rabbit and produced a similar ulcer and hypopyon. 1
CASE REPORT
Fig. 1 (Purcell and Krachmer). On admission, the patient's right eye has purulent discharge, injection and Chemosis, and corneal ulcer.
In November 1975, a 44-year-old woman had a one-week history of mild pain over the right eye and maxillary sinus, decreased vision, and eyelid swelling. Her right eye had been "bumped" by her pet dog two days before the onset of symptoms while she was teaching it back flips. There were no systemic symptoms. On admission, visual acuity was R.E.: light perception with projection, and L.E.: 6/9 (20/30). She was afebrile. Both eyes were proptotic. Hertel exophfhalmometer readings were R.E.: 29 and L . E . : 28 with a baseline of 105. Tenderness and swelling were present over the right maxillary sinus and her eyelids were red and swollen. The conjunctiva was diffusely injected and chemotic (Fig. 1) and an infected corneal ulcer with hypopyon involved the entire cornea with thinning nasally in a ring-shaped fashion. The conjunctiva had deposits of yellow tapioca-colored material temporally. The iris and remainder of the eye were barely visible. A tender right preauricular node was palpated. The left eye was proptotic but otherwise normal. The ulcer bed and margins were scraped with a spatula (Kimura). Gram and Giemsa stains as well as culture for aerobic and anaerobic bacteria, atypical mycobacteria, and fungi were performed. Gram
From the Department of Ophthalmology, University of Iowa College of Medicine, Iowa City, Iowa. Reprint requests to Jay H. Krachmer, M.D., C. S. O'Brien Library, Department of Ophthalmology, University Hospitals, Iowa City, IA 52242. 540
stain revealed gram-negative coccobacillary forms and gram-negative rods as well as many polymorphonuclear cells. Echography revealed no orbital masses, a normal vitreous body and retina, and thickening of the extraocular muscles of both eyes consistent with Graves' disease. Examination of the ear, nose, throat, and paranasal sinuses including radiologic evaluation was normal. The initial impression was exophthalmos secondary to Graves' disease, and corneal ulceration and hypopyon caused by a gram-negative organism. The patient was given 100 mg of methicillin and 20 mg of gentamicin subconjunctival^, every 12 hours for four days, and 500 mg of ampicillin by mouth, every six hours weekly. Fortified gentamicin eyedrops (8 mg/ml) and polymyxin B-neomycin-gramicidin eyedrops (Neosporin) were given every half hour around the clock for three days and then hourly for three more days. Atropine 1% and phenylephrine (Neo-Synephrine) 10% were instilled twice daily. Acetylcysteine 20% was instilled every four hours. Cultures revealed a heavy growth of a pleomorphic gram-negative organism on several media and fermentation and biochemical tests proved this to be P. multocida. By the fifth day the eye appeared quieter and the cornea was becoming reepithelialized. Prednisolone 1% was begun twice daily, and the antibiotic eyedrops were decreased to every two hours. The corticosteroid was increased to four times daily as the inflammation slowly decreased and epithelialization increased. The patient was discharged after 18 days with a persistent epithelial defect and an organized
PASTEURELLA
VOL. 83, NO. 4
MULTOCIDA
541
CORNEAL ULCER
hypopyon. Twelve days after discharge she had pain and a hyphema. She denied trauma. An epithelial defect was treated with pressure patching and it slowly epithelialized. The hyphema resolved. The eye is quiet with a corneal scar and cataract (Fig. 2). She is comfortable and visual acuity is counting lingers. To determine whether the organism isolated from the patient was capable of causing this corneal response, material from the infected cornea was inoculated onto the right cornea of a 2.074-g male Dutch rabbit after the epithelium had been abraded by a tuberculin syringe. The rabbit's fellow eye was abraded and inoculated with normal saline as a control. In three days a corneal ulcer developed on the right eye and by eight days a florid ulceration and hypopyon were present (Fig. 3). Culture, sensitivity studies, and biochemical tests of the organism from the rabbit corneal ulcer were identical to those of the patient and revealed P. multocida. DISCUSSION
Pasteurella multocida is a pleomorphic, gram-negative, non-motile coccobacillus with bipolar staining, and is in the normal flora of the upper respiratory system of many animals. In man, infection caused b y Pasteurella has been recorded in animal bites, meningitis, brain abscess, mastoiditis, sinusitis, pyogenic arthritis, bacteremia, bronchiectasis, appendiceal abscess, pneumonia, bronchiectasis, endocarditis, and pyelonephritis. T h e organism was isolated in the case of panophthalmitis secondary to a cat scratch. T w o cases of conjunctivitis, one of keratitis and one of proptosis from pansinusitis, were recorded in an epidemiologic study in the United States from 2
1
3
Fig. 3 (Purcell and Krachmer). Right eye of rabbit eight days after inoculation with scraping of patient's corneal ulcer.
1 9 6 5 through 1 9 6 8 . L i n d n e r reported four cases of corneal ulcer presumably caused by P. multocida, although he did not fulfill biochemical criteria for isolation of the organism. Conjunctivitis is rarely caused b y P. multocida, and few cases have been recorded. T h e inoculation on an abraded rabbit cornea and subsequent ulceration suggest that this organism is virulent toward the cornea if the epithelium is not intact. Since a variety of domestic and wild animals harbor this organism it should be suspected in all corneal ulcers with a history of animal contact. O n e does not have to be bitten but can acquire the organism from the saliva or respiratory discharge of animals. 4
5
6
4
SUMMARY
Fig. 2 (Purcell and Krachmer). Three months after admission, the corneal scar and thinning remain after the ulcer has healed.
A 44-year-old woman with Graves' disease and exophthalmos developed a severe corneal ulcer caused by Pasteurella multocida after being b u m p e d on her right eye by her pet dog. T h e organism was transferred from the patient to an
542
AMERICAN JOURNAL O F OPHTHALMOLOGY
abraded rabbit cornea and produced a similiar corneal ulcer and hypopyon. REFERENCES
1. Swartz, M. N., and Kunz, L. J . : Pasteurella multocida infections in man. N. Eng. J . Med. 261: 889, 1959. 2. De Boer, R. G., and Dumler, M.: Pasteurella multocida infections. Am. J . Clin. Pathol. 40:339, 1963.
APRIL, 1977
3. Galloway, N. R., and Robinson, G. E.: Panophthalmitis due to Pasteurella séptica. Br. J. Ophthalmol. 57:153, 1973. 4. Hubbert, W. T., and Rosen, M. N.: Pasteurella multocida infection in man unrelated to animal bite, Am. J. Publ. Health. 60:1109, 1970. 5. Lindner, K.: Ulcus Serpens fulminans. Z. Augenheilkd. 52:61, 1924. 6. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1964, p. 210.