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Postcataract endophthalmitis caused by Mycobacterium goodii
Postcataract endophthalmitis caused by Mycobacterium goodii Terrence S. Spencer, MD, Michael P. Teske, MD, Paul S. Bernstein, MD, PhD This is the first reported case of delayed-onset postcataract endophthalmitis caused by Mycobacterium goodii, confirmed by multiple cultures. The patient had uneventful cataract removal by phacoemulsification with implantation of a posterior chamber intraocular lens (IOL). One month later, he developed redness, pain, a hypopyon, and a decrease in visual acuity to finger counting in the affected eye. A vitreous biopsy was performed for suspected endophthalmitis; culture results showed rapidly growing bacteria identified by DNA sequencing as Mycobacterium goodii. The eye ultimately required IOL explantation but had a good final outcome with 20/40 uncorrected vision. Mycobacterium goodii is a rapidly growing Mycobacterium with isolates more commonly occurring in cellulitis, osteomyelitis, and respiratory disease. Single-drug antibiotic therapy for nonocular disease is often sufficient if the correct antimicrobial agent is used. The newer fluoroquinolones are promising against rapidly growing Mycobacterium. J Cataract Refract Surg 2005; 31:1252–1253 ª 2005 ASCRS and ESCRS
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ndophthalmitis after cataract surgery is a rare but serious complication that can result in severe vision loss. Chronic or delayed-onset postoperative endophthalmitis develops 4 or more weeks after surgery and is most commonly associated with Propionibacterium acnes or fungi. There are a few cases of delayed-onset endophthalmitis from Mycobacterium species,1 but to our knowledge, none have been reported from the organism Mycobacterium goodii. One case of low-grade delayed-onset postoperative endophthalmitis caused by Mycobacterium chelonae after extracapsular cataract extraction with posterior chamber intraocular lens (IOL) implantation resulted in evisceration. We report
Accepted for publication November 2, 2004. From the Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA. Dr. Bernstein is a Sybil B. Harrington Research to Prevent Blindness scholar in macular degeneration research. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Paul S. Bernstein, MD, PhD, Moran Eye Center, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132, USA. E-mail: [email protected]. 2005 ASCRS and ESCRS Published by Elsevier Inc.
a case of delayed-onset post-cataract endophthalmitis caused by M goodii confirmed by multiple cultures.
Case Report A 67-year-old man had uneventful cataract removal by phacoemulsification with implantation of a posterior chamber IOL in the capsular bag of the left eye. He was referred to our facility on the 28th postoperative day with the complaint of gradually worsening vision, redness, and pain in the affected eye, especially over the previous 2 days. Examination of the left eye revealed a decrease in visual acuity so the patient could barely count fingers in front of his face and an intraocular pressure of 12 mm Hg. The conjunctiva was markedly injected, and the cornea was edematous. The anterior chamber had stationary cells and flare with a 4.0 mm hypopyon. The posterior chamber IOL was well positioned, but there was moderate posterior capsule opacification. The vitreous had cellular debris and a fibrinous reaction. A vitreous biopsy was immediately performed for suspected endophthalmitis. Vancomycin, ceftazidime, and dexamethasone were injected into the vitreous. The eye remained stable over the subsequent 4 days, at which time culture results revealed rapidly growing bacteria suspected on acid-fast stain to be Mycobacterium fortuitum. Subsequently, the organism was identified by DNA sequencing at the Associated Regional and University Pathologists Laboratories as M goodii. The strain was susceptible to amikacin with 0886-3350/05/$-see front matter doi:10.1016/j.jcrs.2004.11.035
CASE REPORTS: SPENCER
a minimum inhibitory concentration of 0.5 mm/mL. The patient had a pars plana vitrectomy with injection of 400 mg amikacin into the vitreous. A second vitreous sample was sent for culture and again grew M goodii. Following the vitrectomy, the patient’s visual acuity gradually improved over 5 weeks to 20/60. One week later, the patient presented with pain, redness, floaters, and worsening vision in the affected eye. Examination revealed anterior chamber inflammation, vitreous debris, and 20/100 vision. The lens capsule was opacified with ‘‘chalky white’’ deposits and satellite lesions. The patient had a second vitrectomy and injection of amikacin, this time with removal of the IOL and lens capsule. Vitreous samples again grew M goodii. Special stains on the lens capsule for acid-fast bacilli were negative. Over the months following IOL removal, the inflammation in the affected eye quieted. The patient was aphakic however, with the development of an epiretinal membrane. Eight months after the IOL and capsule removal, the patient had an elective vitrectomy, epiretinal membrane peeling, and placement of a secondary anterior chamber IOL. The eye has healed, and the uncorrected visual acuity is 20/40.
Discussion Mycobacterium goodii, a rapidly growing mycobacterium of the Mycobacterium smegmatis group, was named in 1999.2 Isolates have been recovered from patients with cellulitis, osteomyelitis following trauma, and respiratory disease.3 Isolates have also been recovered from health care–associated disease, including bacteremia with catheter sepsis, cardiac bypass infection with osteomyelitis, infected pacemaker site, and in-
fection following breast reduction surgery. These organisms grow in culture on multiple types of media within 7 days. Laboratory testing for these organisms includes phenotypic testing and DNA sequencing. Single-drug therapy for localized nonocular disease due to rapidly growing mycobacterium is often sufficient if the correct antimicrobial agent is used, including amikacin, imipenem, trimethoprim/sulfamethoxazole, and fluoroquinolones. In this patient, however, the infection was not effectively treated until the intraocular lens and capsule were removed. The newer fluoroquinolones moxifloxacin and gatifloxacin are promising against rapidly growing mycobacterium, but clinical experience with them is limited.
References 1. Ramaswamy AA, Biswas J, Bhaskar V, et al. Postoperative Mycobacterium chelonae endophthalmitis after extracapsular cataract extraction and posterior chamber intraocular lens implantation. Ophthalmology 2000; 107:1283–1286 2. Brown BA, Springer B, Steingrube VA, et al. Mycobacterium wolinsky sp nov and Mycobacterium goodii sp nov, two new rapidly growing species related to Mycobacterium smegmatis and associated with human wound infections: a cooperative study from the International Working Group on Mycobacterial Taxonomy. Int J Syst Bacteriol 1999; 49:1493–1511 3. Pfyffer GE, Brown-Elliot BA, Wallace RJ Jr. Mycobacterium: general characteristics, isolation, and staining procedures. In: Murray PR, Baron EJ, Jorgensen JH, et al, eds, Manual of Clinical Microbiology, 8th ed. Washington, DC, American Society for Microbiology, 2003; 539–540
J CATARACT REFRACT SURG—VOL 31, JUNE 2005
1253
E
ndophthalmitis after cataract surgery is a rare but serious complication that can result in severe vision loss. Chronic or delayed-onset postoperative endophthalmitis develops 4 or more weeks after surgery and is most commonly associated with Propionibacterium acnes or fungi. There are a few cases of delayed-onset endophthalmitis from Mycobacterium species,1 but to our knowledge, none have been reported from the organism Mycobacterium goodii. One case of low-grade delayed-onset postoperative endophthalmitis caused by Mycobacterium chelonae after extracapsular cataract extraction with posterior chamber intraocular lens (IOL) implantation resulted in evisceration. We report
Accepted for publication November 2, 2004. From the Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA. Dr. Bernstein is a Sybil B. Harrington Research to Prevent Blindness scholar in macular degeneration research. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Paul S. Bernstein, MD, PhD, Moran Eye Center, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132, USA. E-mail: [email protected]. 2005 ASCRS and ESCRS Published by Elsevier Inc.
a case of delayed-onset post-cataract endophthalmitis caused by M goodii confirmed by multiple cultures.
Case Report A 67-year-old man had uneventful cataract removal by phacoemulsification with implantation of a posterior chamber IOL in the capsular bag of the left eye. He was referred to our facility on the 28th postoperative day with the complaint of gradually worsening vision, redness, and pain in the affected eye, especially over the previous 2 days. Examination of the left eye revealed a decrease in visual acuity so the patient could barely count fingers in front of his face and an intraocular pressure of 12 mm Hg. The conjunctiva was markedly injected, and the cornea was edematous. The anterior chamber had stationary cells and flare with a 4.0 mm hypopyon. The posterior chamber IOL was well positioned, but there was moderate posterior capsule opacification. The vitreous had cellular debris and a fibrinous reaction. A vitreous biopsy was immediately performed for suspected endophthalmitis. Vancomycin, ceftazidime, and dexamethasone were injected into the vitreous. The eye remained stable over the subsequent 4 days, at which time culture results revealed rapidly growing bacteria suspected on acid-fast stain to be Mycobacterium fortuitum. Subsequently, the organism was identified by DNA sequencing at the Associated Regional and University Pathologists Laboratories as M goodii. The strain was susceptible to amikacin with 0886-3350/05/$-see front matter doi:10.1016/j.jcrs.2004.11.035
CASE REPORTS: SPENCER
a minimum inhibitory concentration of 0.5 mm/mL. The patient had a pars plana vitrectomy with injection of 400 mg amikacin into the vitreous. A second vitreous sample was sent for culture and again grew M goodii. Following the vitrectomy, the patient’s visual acuity gradually improved over 5 weeks to 20/60. One week later, the patient presented with pain, redness, floaters, and worsening vision in the affected eye. Examination revealed anterior chamber inflammation, vitreous debris, and 20/100 vision. The lens capsule was opacified with ‘‘chalky white’’ deposits and satellite lesions. The patient had a second vitrectomy and injection of amikacin, this time with removal of the IOL and lens capsule. Vitreous samples again grew M goodii. Special stains on the lens capsule for acid-fast bacilli were negative. Over the months following IOL removal, the inflammation in the affected eye quieted. The patient was aphakic however, with the development of an epiretinal membrane. Eight months after the IOL and capsule removal, the patient had an elective vitrectomy, epiretinal membrane peeling, and placement of a secondary anterior chamber IOL. The eye has healed, and the uncorrected visual acuity is 20/40.
Discussion Mycobacterium goodii, a rapidly growing mycobacterium of the Mycobacterium smegmatis group, was named in 1999.2 Isolates have been recovered from patients with cellulitis, osteomyelitis following trauma, and respiratory disease.3 Isolates have also been recovered from health care–associated disease, including bacteremia with catheter sepsis, cardiac bypass infection with osteomyelitis, infected pacemaker site, and in-
fection following breast reduction surgery. These organisms grow in culture on multiple types of media within 7 days. Laboratory testing for these organisms includes phenotypic testing and DNA sequencing. Single-drug therapy for localized nonocular disease due to rapidly growing mycobacterium is often sufficient if the correct antimicrobial agent is used, including amikacin, imipenem, trimethoprim/sulfamethoxazole, and fluoroquinolones. In this patient, however, the infection was not effectively treated until the intraocular lens and capsule were removed. The newer fluoroquinolones moxifloxacin and gatifloxacin are promising against rapidly growing mycobacterium, but clinical experience with them is limited.
References 1. Ramaswamy AA, Biswas J, Bhaskar V, et al. Postoperative Mycobacterium chelonae endophthalmitis after extracapsular cataract extraction and posterior chamber intraocular lens implantation. Ophthalmology 2000; 107:1283–1286 2. Brown BA, Springer B, Steingrube VA, et al. Mycobacterium wolinsky sp nov and Mycobacterium goodii sp nov, two new rapidly growing species related to Mycobacterium smegmatis and associated with human wound infections: a cooperative study from the International Working Group on Mycobacterial Taxonomy. Int J Syst Bacteriol 1999; 49:1493–1511 3. Pfyffer GE, Brown-Elliot BA, Wallace RJ Jr. Mycobacterium: general characteristics, isolation, and staining procedures. In: Murray PR, Baron EJ, Jorgensen JH, et al, eds, Manual of Clinical Microbiology, 8th ed. Washington, DC, American Society for Microbiology, 2003; 539–540
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