Ring Infiltrate in Staphylococcal Keratitis · 1 Ring Infiltrate in Staphylococcal Keratitis 1...
Transcript of Ring Infiltrate in Staphylococcal Keratitis · 1 Ring Infiltrate in Staphylococcal Keratitis 1...
Ring Infiltrate in Staphylococcal Keratitis 1
1 Batriti S Wallang, DO 1 Sujata Das, MS, FRCS (Glasg.) 2 Savitri Sharma, MD 1 Srikant K Sahu, MS 3 Ruchi Mittal, MD
1 Cornea and Anterior Segment Service 2 Ocular Microbiology Service 3 Ocular Pathology Service
L. V. Prasad Eye Institute, Bhubaneswar, Odisha, India, 751024
Key Word : Ring infiltrate, Staphylococcous infection, Cornea, Keratitis
Financial Support : None.
Conflict of Interest : No conflicting relationship exists for any author.
Running Head : Corneal Ring Infiltrate
Address for Reprints
Sujata Das, MS, FRCS (Glasg.) Consultant, Cornea and Anterior Segment Service L. V. Prasad Eye Institute Bhubaneswar, Odisha India, 751024 T: +91 (674) 398-7999 F: +91 (674) 398-7130 [email protected]
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Copyright © 2012, American Society for Microbiology. All Rights Reserved.J. Clin. Microbiol. doi:10.1128/JCM.02191-12 JCM Accepts, published online ahead of print on 24 October 2012
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ABSTRACT 3
Smear and culture of the corneal scrapings from a patient with a ring infiltrate confirmed 4
significant growth of Staphylococcus species, resistant to fluoroquinolones. Due to non-5
response to medical management, patient underwent therapeutic penetrating keratoplasty. 6
Staphylococcous infection of the cornea may present as ring like infiltrate and recalcitrant to 7
medical management. 8
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CASE REPORT 10
A 66-year-old man presented with complaints of sudden diminution of vision in his left eye for 11
four days. He had undergone left eye punctoplasty for lower lid punctal stenosis in the past and 12
was receiving treatment for chronic meibomitis. He also had a history of recurrent uveitis and 13
secondary glaucoma in this eye. At the time of presentation, he was using loteprednol 14
etabonate (0.5%) and brimonidine tartrate (0.2%) eye-drops twice daily. 15
During presentation his visual acuity was hand movement close to face. Corneal 16
examination revealed a large epithelial defect measuring 8.0x7.5mm. Stromal ring infiltrate was 17
present corresponding to the dimensions of the epithelial defect (Figure-1a,b). It was 18
approximately 1.5mm wide and away from the limbus with associated surrounding stromal 19
edema. The anterior chamber showed a hypopyon measuring 2mm in height. While KOH+CFW 20
(10% potassium hydroxide with calcofluor white) stain did not show any organism, Gram stain 21
showed plenty of polymorphonuclear cells and gram-positive cocci in groups. 22
The patient was put on fortified cefazolin (5%) and gatifloxacin (0.3%) eye-drops one-23
hourly. Culture grew Staphylococcus species (non-S. aureus) which was significant (consistent 24
in direct microscopy result and confluent growth in two solid media), and sensitive to 25
vancomycin, cefazolin and methicillin. Hence, cefazolin 5% eye drops were continued. 26
On subsequent follow-up, persistent epithelial defect of size >8mm in all dimensions, deep 27
stromal ring infiltrate and hypopyon remained same. Loteprednol etabonate eye-drop four-times 28
daily was added on 5th day of presentation for control of inflammatory component along with 29
intensive lubrication. It was tapered over a period of four weeks. A repeat corneal scraping, 26 30
days after presentation, revealed no organisms in direct smear by Gram and KOH+CFW 31
staining as well as in culture. Finally, with the failure in resolution of clinical signs and 32
symptoms, the patient was given the option of left eye therapeutic penetrating keratoplasty. 33
Culture of the corneal tissue for bacteria, fungus and Acanthamoeba did not grow any 34
organism. The histopathology evaluation of the corneal tissue showed completely denuded 35
epithelium with continuous Bowman’s membrane. Stroma showed diffuse loss of 36
fibrokeratocytic nuclei in stroma (Figure-1c,d). Peripheral stroma showed presence of plump 37
myofibroblastic cells. Central and paracentral corneal stroma showed patchy stromal necrosis 38
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with eosinophilic granular debris between the stromal fibres. Descemets membrane was 39
continuous with occasional subendothelial polymorphonuclear cells. Special stains did not show 40
any organism. 41
Postoperatively, there was large epithelial defect in the graft, which was managed with 42
bandage contact lens. At his last follow-up, the visual acuity was 20/125 with a clear graft. 43
DISCUSSION 44
Corneal ring infiltrates have been described to occur in infections by a variety of organisms. 45
These include Acanthamoeba, gram-negative bacilli like Pseudomonas aeruginosa or 46
Moraxella, herpes simplex virus, fungi, varicella zoster virus, as well as immune-related 47
conditions like rheumatoid arthritis.1-3 Corneal ring infiltrates are most consistently associated 48
with Acanthamoeba keratitis. Ring infiltrate has been reported after corneal collagen 49
crosslinking procedure with postoperative use of contact lens due to polymicrobial infection 50
caused by Streptococcus salivarius, Streptococcus oralis, and coagulase-negative 51
Staphylococcus sp.4 We report an atypical case of corneal ring infiltrate associated with 52
Staphylococcus infection with an unusual clinical course. 53
Staphylococcus keratitis occurs more frequently in compromised cornea such as bullous 54
keratopathy, chronic herpetic keratitis, keratoconjunctivitis sicca, etc. While S. aureus tends to 55
produce a rapidly progressive corneal infiltration and moderate anterior chamber reaction with 56
hypopyon, Staphylococcus species other than S. aureus tend to progress slowly and present as 57
superficial localised infiltrate. Although Staphylococcus has been known to cause ring 58
infiltrates, it is uncommon and there are limited reports of such cases.5,6 More interesting was 59
the clinical course of the disease in this patient, where a persistence of the epithelial defect and 60
infiltrate despite medical therapy, presented a diagnostic and therapeutic dilemma. 61
Ring infiltration with Staphylococcus is thought to be immune-mediated in pathogenesis. It 62
is a type III hypersensitivity reaction to staphylococcal antigens or toxins, resulting in 63
complement activation and influx of polymorphonuclear leucocytes and mononuclear cells that 64
form the infiltrate.7 Clinically, differentiating an infective infiltrate from a sterile infiltrate is 65
difficult, although the management differs significantly in the two. While infective cases would 66
be associated with pain, suppuration, larger epithelial defects with anterior chamber reactions, 67
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sterile infiltrates would be milder in signs and symptoms, and not usually associated with 68
epithelial defects of greater than 2mm.8 69
In our patient, risk factor of chronic meibomitis was present, which is most commonly 70
associated with marginal infiltrate by Staphylococcus infection, and perhaps a localised 71
immunocompromised state from chronic topical steroid use. Despite in-vitro susceptibility-72
based treatment and steroid cover for any immunological component, the patient did not 73
respond to the treatment. Repeat microbiological evaluation and culture of the corneal tissue 74
failed to reveal any organism, while histopathology showed a non-specific stromal necrosis with 75
absence of any inflammatory infiltrate. This might be due to chronic steroid use causing 76
localized immune-suppression. 77
Significant growth of Staphylococcus in culture and non-response to steroid treatment in 78
our patient has proven that there is absence of immunologic component in the pathogenesis of 79
the ring infiltrate. The multidrug resistance may be an association or a coincidental finding of 80
ring infiltrate. 81
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REFERENCES 83
1. Meyers-Elliott RH, Pettit TH, Maxwell WA. Viral antigens in the immune ring of Herpes 84
simplex stromal keratitis. Arch Ophthalmol 1980; 98(5): 897-904. 85
2. Khan AO, Al-Assiri A, Wagoner MD. Ring corneal infiltrate and progressive ring thinning 86
following primary varicella infection. J Pediatr Ophthalmol Strabismus 2008; 45(2): 116-117. 87
3. Illingworth CD, Cook SD. Acanthamoeba keratitis. Surv Ophthalmol 1998; 42(6): 493-508. 88
4. Zamora KV, Males JJ. Polymicrobial keratitis after a collagen cross-linking procedure with 89
postoperative use of a contact lens: a case report. Cornea 2009; 28(4): 474-476. 90
5. Thygeson P. Marginal corneal infiltrates and ulcers. Trans Am Acad Ophthalmol 91
Otolaryngol 1947; 51:198-209. 92
6. Hogan MJ, Diaz-Bonnet V, Okumoto M, Kimura SJ. Experimental staphylococcic keratitis. 93
Invest Ophthalmol 1962; 1: 267-272. 94
7. Chignell AH, Easty DL, Chesterton JR, Thomsitt J. Marginal ulceration of the cornea. Br J 95
Ophthalmol 1970; 54(7): 433-440. 96
8. Stein RM, Clinch TE, Cohen EJ, Genvert GI, Arentsen JJ, Laibson PR. Infected vs sterile 97
corneal infiltrates in contact lens wearers. Am J Ophthalmol 1988; 105(6): 632-636. 98
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FIGURE LEGENDS 100
FIGURE-1 101
Slit-lamp photograph showing ring infiltrate in: (a) Diffuse illumination, and (b) Slit-view. (c) 102
Corneal stroma showing diffuse loss of fibrokeratocytic nuclei with complete absence of 103
inflammatory cells (Periodic Acid-Schiff stain, x100); (d) Eosinophilic granular debris between 104
the stromal fibres (Hematoxylin and Eosin stain, x400). 105
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