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Exophiala jeanselmei causing late endophthalmitis after cataract surgery
TABLE 1. Oligonucleotide Primers Used in Amplification of 16S rDNA From Endophthalmitis Samples Primer pair 8FPL 806R Primer pair MF16 B515 Primer pair 515FPL 13B Primer pair MF91 13B
A: primary PCR 5⬘AGT TTG ATC CTG GCT CAG 3⬘ 5⬘GGA CTA CCA GGG TAT CTA AT 3⬘ A: nested PCR 5⬘TGA AAA ACG ACG GCC AGT TTG AAC GCT GGC GGC AGG CCT 3⬘ 5⬘TGC GTG CGC TTT ACG CCC AGT 3⬘ B: primary PCR 5⬘GTG CCA GCA GCC GCG GTA A 3⬘ 5⬘AGG CCC GGG AAC GTA TTC AC 3⬘ B: nested PCR 5⬘TGA AAA ACG ACG GCC AGT ACT CAA ATG AAT TGA CGG GGG C 3⬘ 5⬘AGG CCC GGG AAC GTA TTC AC 3⬘
*Details of the primers and PCR are as stated in the text and in Knox et al.2
2. Knox CM, Cevellos V, Dean D. 16S ribosomal DNA typing for bacterial keratitis. J Clin Microbiol 1998;36:3492–3496. 3. Hykin PG, Tobal K, McIntyre G, Matheson MM, Towler HMA, Lightman SL. The diagnosis of delayed postoperative endophthalmitis by polymerase chain reaction of bacterial DNA in vitreous samples. J Med Microbiol 1994;40:408 – 415. 4. Bouvet A. Human endocarditis due to nutritionally variant streptococci: Streptococcus adjacnes and Streptococcus defectivus. Eur Heart J 1995;16(suppl B):24 –27. 5. Espinoza R, Kusne S, Pasculle AW, Wada S, Fung J, Rakela J. Leuconostoc bacteremia after liver transplantation: another cause of vancomycin resistant gram-positive infection. Clin Transplant 1997;11:322–324.
followed by nested PCR with species-specific primers for Propionibacterium acnes. Because of the large number of potential pathogens in the setting of acute postoperative endophthalmitis, we sequenced 16S rDNA to permit the identification of specific bacteria by DNA fingerprinting, rather than developing a large panel of primers specific for each potential pathogen. Most importantly, this technique was highly specific; no false-positive results were identified. This is particularly important when one uses PCR because contamination of specimens can present a formidable problem. Two unusual organisms were not detected by our technique. S. defectivus is a nutritionally variant streptococcus that is primarily isolated from the oral cavity and is likely responsible for culture-negative endocarditis.4 Leuconostoc species are vancomycin-resistant streptococcus-like grampositive bacteria that uncommonly cause infection but occasionally are found in central line infections.5 Despite the use of primers that were expected to be complementary to conserved segments of all bacterial 16S rDNA, some organisms show variable sequences in these regions and thus cannot be amplified by these primers. Improvement in primer design will address this problem. Our previous work in the setting of bacterial keratitis and this study suggest that common ocular bacterial pathogens may be readily detected by this approach. 16S rDNA typing holds promise as a relatively rapid method for the identification of bacterial pathogens and will be particularly useful when standard microbiologic tests are negative.
Exophiala jeanselmei Causing Late Endophthalmitis After Cataract Surgery A. L. Hofling-Lima, MD, D. Freitas, MD, O. Fischman, PhD, M. C. Z. Yu, MSc, R. Roizenblatt, MD, and R. Belfort, Jr, MD PURPOSE:
To report two cases of late endophthalmitis caused by Exophiala jeanselmei after cataract surgery. METHODS: Case reports, including clinical evaluation, direct examination, and culture of the aqueous humor. RESULTS: In each case, samples from the anterior chamber had positive growth of yeasts with toruloid hyphae and pseudohyphae. Intravitreal and anterior chamber Accepted for publication May 20, 1999. From the Departments of Ophthalmology (A.L.H.-L., D.F., M.C.Z.Y., R.R., R.B.) and Microbiology (D.F.), Immunology and Parasitology, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Inquiries to Roberto Roizenblatt, MD, R. Tomas Carvalhal 865/102, 04006-003, Sa˜o Paulo-S.P., Brazil; fax: 011-884-0020; e-mail: rroizenblatt@ originet.com.br
REFERENCES
1. Hanna DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122:1–17.
512
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 1999
CONCLUSION:
E. jeanselmei causes a severe intraocular infection and isolation, and identification of the agent ensures proper diagnosis and treatment. After clinical resolution of the infection, careful and long-term follow-up is recommended to promptly detect relapse and immediately reintroduce treatment. (Am J Ophthalmol 1999;128:512–514. © 1999 by Elsevier Science Inc. All rights reserved.)
A
FTER CATARACT SURGERY, LATE ENDOPHTHALMITIS
is less common than early endophthalmitis. The main etiologic agents identified in postoperative endophthalmitis are bacteria such as Staphylococcus aureus, coagulasenegative Staphylococcus, Propionibacterium acnes, and some filamentous fungi.1 Two cases of late postoperative endophthalmitis were identified as being caused by Exophiala jeanselmei.
FIGURE 1. Case 1. Anterior chamber abscess on ophthalmologic examination.
amphotericin B were used in both cases. Apparent clinical resolution was achieved, but after 3 months in one case and 6 months in the other the infection recurred more aggressively, with severe endophthalmitis leading to ocular atrophy.
● CASE 1:
A 67-year-old woman receiving corticosteroid treatment for purpura 9 months after an extracapsular lens extraction with posterior chamber lens implantation exhibited episcleritis, which was relieved by corticosteroid eyedrops. In the following months, she complained of pain and decreased visual acuity. A corneoscleral abscess involving the anterior chamber and iris was easily observed under slit-lamp examination (Figure 1). The direct micro-
FIGURE 2. (Left) Conidiogenous cell with conidia on slide culture (arrow) (lactophenol cotton blue stain, ⴛ400 before 93% reduction). (Right) E. jeanselmei (culture on Saboraud medium).
VOL. 128, NO. 4
BRIEF REPORTS
513
Periocular Abscess and Cellulitis From Pasteurella multocida in a Healthy Child
scopic examination of the aqueous humor identified structures such as yeasts, and the positive growth on cultures isolated a filamentous fungi identified as E. jeanselmei. The patient was treated with three intravitreal and three subconjunctival amphotericin B injections, with full remission of the infection in 2 months. Six months later, the patient returned with the same initial symptoms but with a severe anterior chamber and vitreous reaction. Despite repeated injections of amphotericin B, the eye became atrophic with visual acuity of light perception.
Kelly A. Hutcheson, MD, and Michael Magbalon, MD PURPOSE:
To examine an unusual cause of periorbital cellulitis, Pasteurella multocida. METHODS: Case report, review of the literature. RESULTS: We treated a 13-year-old previously healthy child who developed Pasteurella preseptal cellulitis secondary to a cat bite and cat scratch. After receiving a dose of intravenous antibiotics and starting oral antibiotics, the child had delayed onset of several abscesses around the right eye, with marked pain and erythema. After incision and drainage, he improved. CONCLUSION: Pasteurella multocida is a rare but potentially serious cause of ocular infection. All cases of potential exposure should be treated promptly and followed until complete resolution of infection. (Am J Ophthalmol 1999;128:514 –515. © 1999 by Elsevier Science Inc. All rights reserved.)
● CASE 2:
A 52-year-old woman with controlled diabetes who underwent an extracapsular lens extraction with posterior chamber lens implantation was seen 8 months after surgery with severe iridocyclitis, which was relieved by topical corticosteroids. After 1 month, the inflammation relapsed, and a severe diffuse uveitis with hypopyon was present. Samples from anterior chamber and vitreous had positive growth of a black fungus identified as E. jeanselmei. Treatment with systemic and intraocular amphotericin B was effective. Three months later the severe uveitis returned, and vitrectomy with lens extraction was performed in addition to local and systemic amphotericin B treatment. A corneal perforation was observed and treated with tissular adhesive application. Ocular atrophy developed in the following months.
A
Exophiala genera are widely distributed dematiaceous fungi in the environment and have been described as pathogens in cutaneous, subcutaneous, and opportunist systemic infections in immunocompromised individuals. E. jeanselmei has been described as a pathogen after cataract surgery2 and ocular trauma3 and has been reported to invade contact lens4 and cause keratitis.5 In the preceding cases, microscopic preparations of the biological specimen disclosed yeasts, toruloid hyphae (Figure 2, left), and pseudohyphae. E. jeanselmei, a black fungus, was identified in culture (Figure 2, right). The endophthalmitis caused by E. jeanselmei seems to respond to amphotericin B treatment. However, careful follow-up is recommended after initial apparent resolution, because therapy with antifungals should be reintroduced promptly in case of relapse. REFERENCES
1. Mandelbaum S, Forster S. Exogenous endophthalmitis. In: Pepose JS, Holland GN, Wilhelmus KR, editors. Ocular infection and immunity. St Louis: Mosby, 1995:1298 –1320. 2. Potel J, Rohde G, Seeliger H, Werry H. Exophiala jeanselmei isolated from vitreous material. Mykosen 1984;27:380 –384. 3. Hammer ME, Harding S, Wynn P. Post-traumatic fungal endophthalmitis caused by Exophiala jeanselmei. Ann Ophthalmol 1983;15:853– 855. 4. Hurtado I, Magran BL. Invasion of a soft contact lens by Exophiala jeanselmei. Mycopathologia 1989;105:171–173. 5. Al-Hedaithy SS, Al-Kaff AS. Exophiala jeanselmei keratitis. Mycoses 1993;36:97–100.
514
AMERICAN JOURNAL
13-YEAR-OLD BOY WAS PLAYING WITH A NEIGHBOR’S
cat when he was bitten and scratched over his right eye. He was treated in the emergency department later that day, where a tetanus shot and a single dose of intravenous cefazolin was given. He was started on a 10-day course of oral amoxicillin/clavulanic acid. Overnight, a diffuse preseptal swelling of the eyelids developed. He was initially seen by us the next day. On examination, he had three small puncture wounds over the right eyebrow associated with diffuse erythema and edema of the lids. Visual acuity was 20/20 in both eyes, and pupillary responses were brisk. There was no ocular motility deficit, and the fundus was normal in both eyes. The following day, the patient complained of severe tenderness of the right upper eyelid. The white blood cell count was 11 cells per mm3. At that time, he had several visible abscesses just below the skin surface, directly underlying the three puncture wounds. We promptly incised and drained these lesions, expressing a copious amount of purulent material. The isolate was Pasteurella multocida. The patient completed a 10-day course of oral antibiotics, improving rapidly over the next 3 days, and recovered without sequelae. Animal bites are a significant public health concern, numbering more than 2 million a year in the United States, accounting for 1% of all emergency department Accepted for publication April 16, 1999. From the Department of Ophthalmology, University of Maryland School of Medicine, Baltimore, Maryland. Inquiries to Kelly A. Hutcheson, MD, Director, Pediatric Ophthalmology, University of Maryland School of Medicine, 22 Greene St, 6th Fl, Baltimore, MD 21201.
OF
OPHTHALMOLOGY
OCTOBER 1999
A: primary PCR 5⬘AGT TTG ATC CTG GCT CAG 3⬘ 5⬘GGA CTA CCA GGG TAT CTA AT 3⬘ A: nested PCR 5⬘TGA AAA ACG ACG GCC AGT TTG AAC GCT GGC GGC AGG CCT 3⬘ 5⬘TGC GTG CGC TTT ACG CCC AGT 3⬘ B: primary PCR 5⬘GTG CCA GCA GCC GCG GTA A 3⬘ 5⬘AGG CCC GGG AAC GTA TTC AC 3⬘ B: nested PCR 5⬘TGA AAA ACG ACG GCC AGT ACT CAA ATG AAT TGA CGG GGG C 3⬘ 5⬘AGG CCC GGG AAC GTA TTC AC 3⬘
*Details of the primers and PCR are as stated in the text and in Knox et al.2
2. Knox CM, Cevellos V, Dean D. 16S ribosomal DNA typing for bacterial keratitis. J Clin Microbiol 1998;36:3492–3496. 3. Hykin PG, Tobal K, McIntyre G, Matheson MM, Towler HMA, Lightman SL. The diagnosis of delayed postoperative endophthalmitis by polymerase chain reaction of bacterial DNA in vitreous samples. J Med Microbiol 1994;40:408 – 415. 4. Bouvet A. Human endocarditis due to nutritionally variant streptococci: Streptococcus adjacnes and Streptococcus defectivus. Eur Heart J 1995;16(suppl B):24 –27. 5. Espinoza R, Kusne S, Pasculle AW, Wada S, Fung J, Rakela J. Leuconostoc bacteremia after liver transplantation: another cause of vancomycin resistant gram-positive infection. Clin Transplant 1997;11:322–324.
followed by nested PCR with species-specific primers for Propionibacterium acnes. Because of the large number of potential pathogens in the setting of acute postoperative endophthalmitis, we sequenced 16S rDNA to permit the identification of specific bacteria by DNA fingerprinting, rather than developing a large panel of primers specific for each potential pathogen. Most importantly, this technique was highly specific; no false-positive results were identified. This is particularly important when one uses PCR because contamination of specimens can present a formidable problem. Two unusual organisms were not detected by our technique. S. defectivus is a nutritionally variant streptococcus that is primarily isolated from the oral cavity and is likely responsible for culture-negative endocarditis.4 Leuconostoc species are vancomycin-resistant streptococcus-like grampositive bacteria that uncommonly cause infection but occasionally are found in central line infections.5 Despite the use of primers that were expected to be complementary to conserved segments of all bacterial 16S rDNA, some organisms show variable sequences in these regions and thus cannot be amplified by these primers. Improvement in primer design will address this problem. Our previous work in the setting of bacterial keratitis and this study suggest that common ocular bacterial pathogens may be readily detected by this approach. 16S rDNA typing holds promise as a relatively rapid method for the identification of bacterial pathogens and will be particularly useful when standard microbiologic tests are negative.
Exophiala jeanselmei Causing Late Endophthalmitis After Cataract Surgery A. L. Hofling-Lima, MD, D. Freitas, MD, O. Fischman, PhD, M. C. Z. Yu, MSc, R. Roizenblatt, MD, and R. Belfort, Jr, MD PURPOSE:
To report two cases of late endophthalmitis caused by Exophiala jeanselmei after cataract surgery. METHODS: Case reports, including clinical evaluation, direct examination, and culture of the aqueous humor. RESULTS: In each case, samples from the anterior chamber had positive growth of yeasts with toruloid hyphae and pseudohyphae. Intravitreal and anterior chamber Accepted for publication May 20, 1999. From the Departments of Ophthalmology (A.L.H.-L., D.F., M.C.Z.Y., R.R., R.B.) and Microbiology (D.F.), Immunology and Parasitology, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Inquiries to Roberto Roizenblatt, MD, R. Tomas Carvalhal 865/102, 04006-003, Sa˜o Paulo-S.P., Brazil; fax: 011-884-0020; e-mail: rroizenblatt@ originet.com.br
REFERENCES
1. Hanna DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122:1–17.
512
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 1999
CONCLUSION:
E. jeanselmei causes a severe intraocular infection and isolation, and identification of the agent ensures proper diagnosis and treatment. After clinical resolution of the infection, careful and long-term follow-up is recommended to promptly detect relapse and immediately reintroduce treatment. (Am J Ophthalmol 1999;128:512–514. © 1999 by Elsevier Science Inc. All rights reserved.)
A
FTER CATARACT SURGERY, LATE ENDOPHTHALMITIS
is less common than early endophthalmitis. The main etiologic agents identified in postoperative endophthalmitis are bacteria such as Staphylococcus aureus, coagulasenegative Staphylococcus, Propionibacterium acnes, and some filamentous fungi.1 Two cases of late postoperative endophthalmitis were identified as being caused by Exophiala jeanselmei.
FIGURE 1. Case 1. Anterior chamber abscess on ophthalmologic examination.
amphotericin B were used in both cases. Apparent clinical resolution was achieved, but after 3 months in one case and 6 months in the other the infection recurred more aggressively, with severe endophthalmitis leading to ocular atrophy.
● CASE 1:
A 67-year-old woman receiving corticosteroid treatment for purpura 9 months after an extracapsular lens extraction with posterior chamber lens implantation exhibited episcleritis, which was relieved by corticosteroid eyedrops. In the following months, she complained of pain and decreased visual acuity. A corneoscleral abscess involving the anterior chamber and iris was easily observed under slit-lamp examination (Figure 1). The direct micro-
FIGURE 2. (Left) Conidiogenous cell with conidia on slide culture (arrow) (lactophenol cotton blue stain, ⴛ400 before 93% reduction). (Right) E. jeanselmei (culture on Saboraud medium).
VOL. 128, NO. 4
BRIEF REPORTS
513
Periocular Abscess and Cellulitis From Pasteurella multocida in a Healthy Child
scopic examination of the aqueous humor identified structures such as yeasts, and the positive growth on cultures isolated a filamentous fungi identified as E. jeanselmei. The patient was treated with three intravitreal and three subconjunctival amphotericin B injections, with full remission of the infection in 2 months. Six months later, the patient returned with the same initial symptoms but with a severe anterior chamber and vitreous reaction. Despite repeated injections of amphotericin B, the eye became atrophic with visual acuity of light perception.
Kelly A. Hutcheson, MD, and Michael Magbalon, MD PURPOSE:
To examine an unusual cause of periorbital cellulitis, Pasteurella multocida. METHODS: Case report, review of the literature. RESULTS: We treated a 13-year-old previously healthy child who developed Pasteurella preseptal cellulitis secondary to a cat bite and cat scratch. After receiving a dose of intravenous antibiotics and starting oral antibiotics, the child had delayed onset of several abscesses around the right eye, with marked pain and erythema. After incision and drainage, he improved. CONCLUSION: Pasteurella multocida is a rare but potentially serious cause of ocular infection. All cases of potential exposure should be treated promptly and followed until complete resolution of infection. (Am J Ophthalmol 1999;128:514 –515. © 1999 by Elsevier Science Inc. All rights reserved.)
● CASE 2:
A 52-year-old woman with controlled diabetes who underwent an extracapsular lens extraction with posterior chamber lens implantation was seen 8 months after surgery with severe iridocyclitis, which was relieved by topical corticosteroids. After 1 month, the inflammation relapsed, and a severe diffuse uveitis with hypopyon was present. Samples from anterior chamber and vitreous had positive growth of a black fungus identified as E. jeanselmei. Treatment with systemic and intraocular amphotericin B was effective. Three months later the severe uveitis returned, and vitrectomy with lens extraction was performed in addition to local and systemic amphotericin B treatment. A corneal perforation was observed and treated with tissular adhesive application. Ocular atrophy developed in the following months.
A
Exophiala genera are widely distributed dematiaceous fungi in the environment and have been described as pathogens in cutaneous, subcutaneous, and opportunist systemic infections in immunocompromised individuals. E. jeanselmei has been described as a pathogen after cataract surgery2 and ocular trauma3 and has been reported to invade contact lens4 and cause keratitis.5 In the preceding cases, microscopic preparations of the biological specimen disclosed yeasts, toruloid hyphae (Figure 2, left), and pseudohyphae. E. jeanselmei, a black fungus, was identified in culture (Figure 2, right). The endophthalmitis caused by E. jeanselmei seems to respond to amphotericin B treatment. However, careful follow-up is recommended after initial apparent resolution, because therapy with antifungals should be reintroduced promptly in case of relapse. REFERENCES
1. Mandelbaum S, Forster S. Exogenous endophthalmitis. In: Pepose JS, Holland GN, Wilhelmus KR, editors. Ocular infection and immunity. St Louis: Mosby, 1995:1298 –1320. 2. Potel J, Rohde G, Seeliger H, Werry H. Exophiala jeanselmei isolated from vitreous material. Mykosen 1984;27:380 –384. 3. Hammer ME, Harding S, Wynn P. Post-traumatic fungal endophthalmitis caused by Exophiala jeanselmei. Ann Ophthalmol 1983;15:853– 855. 4. Hurtado I, Magran BL. Invasion of a soft contact lens by Exophiala jeanselmei. Mycopathologia 1989;105:171–173. 5. Al-Hedaithy SS, Al-Kaff AS. Exophiala jeanselmei keratitis. Mycoses 1993;36:97–100.
514
AMERICAN JOURNAL
13-YEAR-OLD BOY WAS PLAYING WITH A NEIGHBOR’S
cat when he was bitten and scratched over his right eye. He was treated in the emergency department later that day, where a tetanus shot and a single dose of intravenous cefazolin was given. He was started on a 10-day course of oral amoxicillin/clavulanic acid. Overnight, a diffuse preseptal swelling of the eyelids developed. He was initially seen by us the next day. On examination, he had three small puncture wounds over the right eyebrow associated with diffuse erythema and edema of the lids. Visual acuity was 20/20 in both eyes, and pupillary responses were brisk. There was no ocular motility deficit, and the fundus was normal in both eyes. The following day, the patient complained of severe tenderness of the right upper eyelid. The white blood cell count was 11 cells per mm3. At that time, he had several visible abscesses just below the skin surface, directly underlying the three puncture wounds. We promptly incised and drained these lesions, expressing a copious amount of purulent material. The isolate was Pasteurella multocida. The patient completed a 10-day course of oral antibiotics, improving rapidly over the next 3 days, and recovered without sequelae. Animal bites are a significant public health concern, numbering more than 2 million a year in the United States, accounting for 1% of all emergency department Accepted for publication April 16, 1999. From the Department of Ophthalmology, University of Maryland School of Medicine, Baltimore, Maryland. Inquiries to Kelly A. Hutcheson, MD, Director, Pediatric Ophthalmology, University of Maryland School of Medicine, 22 Greene St, 6th Fl, Baltimore, MD 21201.
OF
OPHTHALMOLOGY
OCTOBER 1999