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Necrotizing Ring Ulcer of the Cornea Caused by Exogenous Listeria monocytogenes Serotype IV b Infection
Vol. 106, No. 1
Letters to the Journal
References 1. McLean, A. L.: Spray keratitis. A common epithelial keratitis from noncorrosive household sprays. Trans. Am. Acad. Ophthalmol. Otolaryngol. 71:330, 1967. 2. Bonnet, L: Bilateral corneal lesions due to the projections of cosmetics and hygienic products by aerosols. Bull. Soc. Ophthalmol. Fr. 73:767, 1973. 3. Carella, G. L., Trimarchi, F., and Asperti, G.: Keratopathy caused by sprays. Ann Ottalmol. Clin. Oculist. 94:571, 1968. 4. Thygeson, P.: Superficial punctate keratitis. JAMA 144:1544, 1950.
Necrotizing Ring Ulcer of the Cornea Caused by Exogenous Listeria monocytogenes Serotype IV b Infection L. M . H o l b a c h , M . D . , A. A. Bialasiewicz, M . D . , a n d H . J. B o l t z e , M . D . University Eye Hospital (L.M.H. and A.A.B.) and Institute tor Clinical Microbiology (H.J.B.), University of Erlangen-Nürnberg. Inquiries to A. A. Bialasiewicz, Μ.Ό., Univ. Eye Hospi tal Erlangen-Nürnberg, Schwabachanlage 6, D-8520 Erlangen, West Germany. Listeria monocytogenes is a g r a m - p o s i t i v e , n o n s p o r e f o r m i n g , non-acid-fast, d i p h t h e r o i d l i k e
r o d w i t h a t u m b l i n g motility at r o o m t e m p e r a ture, which may cause life-threatening granul o m a t o u s l e s i o n s in n e w b o r n s a n d a d u l t s . 1 End o p h t h a l m i t i s c a u s e d by L. monocytogenes is e x t r e m e l y rare. 2 ' 5 A n 86-year-old w o m a n w h o w a s diabetic h a d a n e x o g e n o u s L. monocytogenes infection w i t h a c o r n e a l r i n g ulcer. S h e h a d h a d p a i n , r e d n e s s , a n d d e c r e a s e d vision of t h e r i g h t eye for t h r e e w e e k s . T h e p a t i e n t h a d n o a n i m a l e x p o s u r e or p r e v i o u s ocular d i s e a s e s . U n t r e a t e d d i a b e t e s m e l l i t u s h a d b e e n k n o w n for ten y e a r s . Visual acuity w a s R.E.: 1/50 a n d L.E.: 20/30. Intraocular p r e s s u r e w a s 16 m m H g in b o t h e y e s . C o r n e al s e n s i t i v i t y w a s n o t d e c r e a s e d . Slit-lamp examination of the right eye disclosed conjunctival chemosis, and a peripheral corneal ulcer in t h e 8 to 9 o'clock m e r i d i a n w i t h e x t e n s i v e s t r o m a l infiltration a c c o m p a n i e d by a 2 - m m h y p o p y o n a n d fibrinous e x u d a t e in the a n t e r i o r c h a m b e r , p r e v e n t i n g v i s u a l i z a t i o n of t h e f u n d u s (Fig. 1). T h e left eye h a d cortical cataract a n d c h o r o i d a l sclerosis. L a b o r a t o r y s t u d i e s of s m e a r s t a k e n from t h e c o r n e a l ulcer d i s c l o s e d L. monocytogenes serot y p e IV b . D e s p i t e s y s t e m i c antibiotic t h e r a p y i n c l u d i n g 2 g of cefotiam t h r e e t i m e s a d a y a n d 500 m g of a m i k a c i n twice a d a y c o m b i n e d w i t h g e n t a m i c i n e y e d r o p s e v e r y 15 m i n u t e s according to antibiotic susceptibility tests, i n t e n s e flare a n d fibrinous r e a c t i o n w i t h a b r o w n h y p o p y o n as well as a s e c o n d a r y increase of intraocu l a r p r e s s u r e w i t h e x t r e m e p a i n r e s u l t e d in t h e p a t i e n t ' s refusal to eat. T h e eye w a s s u b s e q u e n t l y e n u c l e a t e d o n t h e 16th d a y after a d m i s sion. A q u e o u s h u m o r t a k e n p e r i o p e r a t i v e l y did
4
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Fig. 1 (Holbach, Bialasiewicz, and Boltze). Conjunctival chemosis and corneal ulcer (8 to 9 o'clock meridian) with stromal infiltration, large retrocorneal precipitates, and fibrin in the anterior chamber.
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Fig. 2 (Holbach, Bialasiewicz, and Boltze). Positive reaction products (arrows) utilizing rabbit antiL/sfen'fl-O-serum in sections of peripheral necrotizing corneal stroma (peroxidase-antiperoxidase, Boehmer's hematoxylin, x 1,200).
106
AMERICAN JOURNAL OF OPHTHALMOLOGY
not grow bacteria. After removal of the globe the patient improved dramatically. Histologie examination showed a necrotizing ring ulcer of the cornea with a dense cellular stromal infiltration, mainly composed of polymorphonuclear leukocytes, lymphocytes, plasma cells, and cellular debris. Evidence for the Listeria infection was found by immunoperoxidase staining using a rabbit anti-Listeria-Oserum (Fig. 2). A polymorphonuclear reaction could be seen in the anterior chamber as well as massive fibrinous exudate. The posterior segment of the eye did not show signs of inflammation. Ocular complications of L. monocy togenes infections are known to pose therapeutic problems. None of the affected subjects described to date have achieved a better visual acuity than 20/200.2S Application of corticosteroids has not been proven beneficial. We propose immediate referral of patients with corneal ulcers and brown hypopyon, who live in the countryside, for thorough laboratory testing and early antibiotic therapy.
References 1. Gray, M. L., and Killinger, A. H.: Listeria monocytogenes and Listeria infections. Bacteriol. Rev. 30:309, 1966. 2. Ballen, P. H., Loffredo, F. R., and Painter, B.: Listeria enophthalmitis. Arch. Ophthalmol. 97:101, 1979. 3. Abbott, R. L., Forster, R. K., and Rebell, G.: Listeria monocytogenes endophthalmitis with a black hypopyon. Am. J. Ophthalmol. 86:715, 1978. 4. Goodner, E. K., and Okumoto, M.: Intraocular listeriosis. Am. J. Ophthalmol. 64:682, 1967. 5. Bagnarello, A. G., Berlin, A. J., Weinstein, A. J., McHenry, M. C., and O'Connor, P. S.: Listeria monocytogenes endophthalmitis. Arch. Ophthalmol. 95:1004, 1977.
Inferior Corneal Ulcers Associated With Palpebrai Vernal Conjunctivitis James D . Shuler, M . D . , Jeremy L e v e n s o n , M . D . , and Bartly J. M o n d i n o , M . D . Department of Ophthalmology and the Jules Stein Eye Institute, UCLA School of Medicine. Inquiries to Bartly J. Mondino, M.D., Jules Stein Eye Institute, 800 Westwood Plaza, Los Angeles, CA 90024.
July, 1988
Vernal conjunctivitis is a bilateral, often recurrent, seasonal inflammation of the conjunctiva that is characterized by a marked papillary reaction of the superior tarsal conjunctiva and limbal region. Vernal conjunctivitis may be associated with corneal complications that include nodular hyperplasia, pannus formation, punctate epithelial erosions, punctate epithelial keratitis, pseudogerontoxon, and keratoconus. 1 ' 2 Vernal ulcerative keratitis is seen with the palpebrai form and is characterized by transversely oval corneal ulcers confined to the superior one half of the cornea. 24 We treated two patients with palpebrai vernal conjunctivitis and ulcerative keratitis involving not only the superior but also the inferior cornea. Casel A 20-year-old man with a history of asthma complained of bilateral eye irritation, redness, and itching associated with swollen eyelids for six weeks. The visual acuity in both eyes was 20/30. Slit-lamp examination disclosed severe conjunctival hyperemia with giant papillae of the superior tarsal conjunctiva in both eyes. The right eye had a transversely oval ulcerative plaque in the superior cornea and a transversely oval stromal infiltrate associated with overlying epithelial defects and vascularization in the inferior cornea. The left eye had almost identical corneal findings. Giemsa stain of superior tarsal conjunctival scrapings showed numerous eosinophils. The patient was treated with topical fluorometholone 0.1% and cromolyn sodium 4%, one drop in each eye four times daily, with prompt resolution of symptoms in one day and epithelialization of the corneal ulcers within four days (Figs. 1 and 2). Case 2 A 23-year-old man with a history of asthma and eczema complained of redness and irritation in both eyes for one month. The visual acuity was 20/200 in the right eye and 20/20 in the left eye. Slit-lamp examination of both eyes disclosed marked giant papillary changes of both upper and lower tarsal conjunctiva with the upper eyelids being worse than the lower eyelids. Both eyes showed conjunctival hyperemia and edema. The right cornea disclosed one superior horizontally oval ulcer and two smaller inferior ulcers, all three of which had plaque-like material at the bases. The left cornea was clear. The patient's symptoms responded to topical fluorometholone 0.1% every three hours in the right eye, but the ulcers failed to heal until a bandage lens was applied.
Letters to the Journal
References 1. McLean, A. L.: Spray keratitis. A common epithelial keratitis from noncorrosive household sprays. Trans. Am. Acad. Ophthalmol. Otolaryngol. 71:330, 1967. 2. Bonnet, L: Bilateral corneal lesions due to the projections of cosmetics and hygienic products by aerosols. Bull. Soc. Ophthalmol. Fr. 73:767, 1973. 3. Carella, G. L., Trimarchi, F., and Asperti, G.: Keratopathy caused by sprays. Ann Ottalmol. Clin. Oculist. 94:571, 1968. 4. Thygeson, P.: Superficial punctate keratitis. JAMA 144:1544, 1950.
Necrotizing Ring Ulcer of the Cornea Caused by Exogenous Listeria monocytogenes Serotype IV b Infection L. M . H o l b a c h , M . D . , A. A. Bialasiewicz, M . D . , a n d H . J. B o l t z e , M . D . University Eye Hospital (L.M.H. and A.A.B.) and Institute tor Clinical Microbiology (H.J.B.), University of Erlangen-Nürnberg. Inquiries to A. A. Bialasiewicz, Μ.Ό., Univ. Eye Hospi tal Erlangen-Nürnberg, Schwabachanlage 6, D-8520 Erlangen, West Germany. Listeria monocytogenes is a g r a m - p o s i t i v e , n o n s p o r e f o r m i n g , non-acid-fast, d i p h t h e r o i d l i k e
r o d w i t h a t u m b l i n g motility at r o o m t e m p e r a ture, which may cause life-threatening granul o m a t o u s l e s i o n s in n e w b o r n s a n d a d u l t s . 1 End o p h t h a l m i t i s c a u s e d by L. monocytogenes is e x t r e m e l y rare. 2 ' 5 A n 86-year-old w o m a n w h o w a s diabetic h a d a n e x o g e n o u s L. monocytogenes infection w i t h a c o r n e a l r i n g ulcer. S h e h a d h a d p a i n , r e d n e s s , a n d d e c r e a s e d vision of t h e r i g h t eye for t h r e e w e e k s . T h e p a t i e n t h a d n o a n i m a l e x p o s u r e or p r e v i o u s ocular d i s e a s e s . U n t r e a t e d d i a b e t e s m e l l i t u s h a d b e e n k n o w n for ten y e a r s . Visual acuity w a s R.E.: 1/50 a n d L.E.: 20/30. Intraocular p r e s s u r e w a s 16 m m H g in b o t h e y e s . C o r n e al s e n s i t i v i t y w a s n o t d e c r e a s e d . Slit-lamp examination of the right eye disclosed conjunctival chemosis, and a peripheral corneal ulcer in t h e 8 to 9 o'clock m e r i d i a n w i t h e x t e n s i v e s t r o m a l infiltration a c c o m p a n i e d by a 2 - m m h y p o p y o n a n d fibrinous e x u d a t e in the a n t e r i o r c h a m b e r , p r e v e n t i n g v i s u a l i z a t i o n of t h e f u n d u s (Fig. 1). T h e left eye h a d cortical cataract a n d c h o r o i d a l sclerosis. L a b o r a t o r y s t u d i e s of s m e a r s t a k e n from t h e c o r n e a l ulcer d i s c l o s e d L. monocytogenes serot y p e IV b . D e s p i t e s y s t e m i c antibiotic t h e r a p y i n c l u d i n g 2 g of cefotiam t h r e e t i m e s a d a y a n d 500 m g of a m i k a c i n twice a d a y c o m b i n e d w i t h g e n t a m i c i n e y e d r o p s e v e r y 15 m i n u t e s according to antibiotic susceptibility tests, i n t e n s e flare a n d fibrinous r e a c t i o n w i t h a b r o w n h y p o p y o n as well as a s e c o n d a r y increase of intraocu l a r p r e s s u r e w i t h e x t r e m e p a i n r e s u l t e d in t h e p a t i e n t ' s refusal to eat. T h e eye w a s s u b s e q u e n t l y e n u c l e a t e d o n t h e 16th d a y after a d m i s sion. A q u e o u s h u m o r t a k e n p e r i o p e r a t i v e l y did
4
' V»
ir-
Fig. 1 (Holbach, Bialasiewicz, and Boltze). Conjunctival chemosis and corneal ulcer (8 to 9 o'clock meridian) with stromal infiltration, large retrocorneal precipitates, and fibrin in the anterior chamber.
105
»
T
Fig. 2 (Holbach, Bialasiewicz, and Boltze). Positive reaction products (arrows) utilizing rabbit antiL/sfen'fl-O-serum in sections of peripheral necrotizing corneal stroma (peroxidase-antiperoxidase, Boehmer's hematoxylin, x 1,200).
106
AMERICAN JOURNAL OF OPHTHALMOLOGY
not grow bacteria. After removal of the globe the patient improved dramatically. Histologie examination showed a necrotizing ring ulcer of the cornea with a dense cellular stromal infiltration, mainly composed of polymorphonuclear leukocytes, lymphocytes, plasma cells, and cellular debris. Evidence for the Listeria infection was found by immunoperoxidase staining using a rabbit anti-Listeria-Oserum (Fig. 2). A polymorphonuclear reaction could be seen in the anterior chamber as well as massive fibrinous exudate. The posterior segment of the eye did not show signs of inflammation. Ocular complications of L. monocy togenes infections are known to pose therapeutic problems. None of the affected subjects described to date have achieved a better visual acuity than 20/200.2S Application of corticosteroids has not been proven beneficial. We propose immediate referral of patients with corneal ulcers and brown hypopyon, who live in the countryside, for thorough laboratory testing and early antibiotic therapy.
References 1. Gray, M. L., and Killinger, A. H.: Listeria monocytogenes and Listeria infections. Bacteriol. Rev. 30:309, 1966. 2. Ballen, P. H., Loffredo, F. R., and Painter, B.: Listeria enophthalmitis. Arch. Ophthalmol. 97:101, 1979. 3. Abbott, R. L., Forster, R. K., and Rebell, G.: Listeria monocytogenes endophthalmitis with a black hypopyon. Am. J. Ophthalmol. 86:715, 1978. 4. Goodner, E. K., and Okumoto, M.: Intraocular listeriosis. Am. J. Ophthalmol. 64:682, 1967. 5. Bagnarello, A. G., Berlin, A. J., Weinstein, A. J., McHenry, M. C., and O'Connor, P. S.: Listeria monocytogenes endophthalmitis. Arch. Ophthalmol. 95:1004, 1977.
Inferior Corneal Ulcers Associated With Palpebrai Vernal Conjunctivitis James D . Shuler, M . D . , Jeremy L e v e n s o n , M . D . , and Bartly J. M o n d i n o , M . D . Department of Ophthalmology and the Jules Stein Eye Institute, UCLA School of Medicine. Inquiries to Bartly J. Mondino, M.D., Jules Stein Eye Institute, 800 Westwood Plaza, Los Angeles, CA 90024.
July, 1988
Vernal conjunctivitis is a bilateral, often recurrent, seasonal inflammation of the conjunctiva that is characterized by a marked papillary reaction of the superior tarsal conjunctiva and limbal region. Vernal conjunctivitis may be associated with corneal complications that include nodular hyperplasia, pannus formation, punctate epithelial erosions, punctate epithelial keratitis, pseudogerontoxon, and keratoconus. 1 ' 2 Vernal ulcerative keratitis is seen with the palpebrai form and is characterized by transversely oval corneal ulcers confined to the superior one half of the cornea. 24 We treated two patients with palpebrai vernal conjunctivitis and ulcerative keratitis involving not only the superior but also the inferior cornea. Casel A 20-year-old man with a history of asthma complained of bilateral eye irritation, redness, and itching associated with swollen eyelids for six weeks. The visual acuity in both eyes was 20/30. Slit-lamp examination disclosed severe conjunctival hyperemia with giant papillae of the superior tarsal conjunctiva in both eyes. The right eye had a transversely oval ulcerative plaque in the superior cornea and a transversely oval stromal infiltrate associated with overlying epithelial defects and vascularization in the inferior cornea. The left eye had almost identical corneal findings. Giemsa stain of superior tarsal conjunctival scrapings showed numerous eosinophils. The patient was treated with topical fluorometholone 0.1% and cromolyn sodium 4%, one drop in each eye four times daily, with prompt resolution of symptoms in one day and epithelialization of the corneal ulcers within four days (Figs. 1 and 2). Case 2 A 23-year-old man with a history of asthma and eczema complained of redness and irritation in both eyes for one month. The visual acuity was 20/200 in the right eye and 20/20 in the left eye. Slit-lamp examination of both eyes disclosed marked giant papillary changes of both upper and lower tarsal conjunctiva with the upper eyelids being worse than the lower eyelids. Both eyes showed conjunctival hyperemia and edema. The right cornea disclosed one superior horizontally oval ulcer and two smaller inferior ulcers, all three of which had plaque-like material at the bases. The left cornea was clear. The patient's symptoms responded to topical fluorometholone 0.1% every three hours in the right eye, but the ulcers failed to heal until a bandage lens was applied.