An outbreak of Mycobacterium chelonae infection after LASIK

Ocular infections associated with atypical mycobacteria: A review

Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes.

Case Commentary: Another prong of attack? Topical antibiotic instillation with negative pressure wound therapy for nontuberculous mycobacterial skin and soft tissue infections

Nontuberculous mycobacteria (NTM) skin infections remain therapeutically challenging. Given the diversity in infections, host responses, and antimicrobials, clinical guidelines are often built on case series and observational studies. In this commentary, we respond to a paper by Stemkens et al. that introduces an emerging strategy: adjunctive negative pressure wound therapy with instillation and dwell time combined with topical antibiotics for refractory NTM skin and soft tissue infections. We delve into the primary considerations surrounding this innovative approach.

Successful addition of topical antibiotic treatment after surgery in treatment-refractory nontuberculous mycobacterial skin and soft tissue infections

Treatment of skin and soft tissue infections with nontuberculous mycobacteria sometimes fails despite repeated debridements and long-term systemic antibiotic therapy. These treatment-refractory infections can cause significant morbidity and pose a treatment challenge. Following surgery, we treated three patients with negative pressure wound therapy with the instillation and dwell time of topical antibiotics, in addition to systemic antibiotic treatment. Treatment was successful and well tolerated, except for some local irritation.

Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature

OBJECTIVES

To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery.

METHODS

To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article.

RESULTS

Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%).

CONCLUSIONS

Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.

Atypical microbial keratitis

Atypical microbial keratitis refers to corneal infections caused by micro-organisms not commonly encountered in clinical practice. Unlike infections caused by common bacteria, cases of atypical microbial keratitis are often associated with worse clinical outcomes and visual prognosis. This is due to the challenges in the identification of causative organisms with standard diagnostic techniques, resulting in delays in the initiation of appropriate therapies. Furthermore, due to the comparatively lower incidence of atypical microbial keratitis, there is limited literature on effective management strategies for some of these difficult to manage corneal infections. This review highlights the current management and available evidence of atypical microbial keratitis, focusing on atypical mycobacteria keratitis, nocardia keratitis, achromobacter keratitis, and pythium keratitis. It will also describe the management of two uncommonly encountered conditions, infectious crystalline keratopathy and post-refractive infectious keratitis. This review can be used as a guide for clinicians managing patients with such challenging corneal infections.

Bacterial keratitis: identifying the areas of clinical uncertainty

Bacterial keratitis is a common corneal infection that is treated with topical antimicrobials. By the time of presentation there may already be severe visual loss from corneal ulceration and opacity, which may persist despite treatment. There are significant differences in the associated risk factors and the bacterial isolates between high income and low- or middle-income countries, so that general management guidelines may not be appropriate. Although the diagnosis of bacterial keratitis may seem intuitive there are multiple uncertainties about the criteria that are used, which impacts the interpretation of investigations and recruitment to clinical studies. Importantly, the concept that bacterial keratitis can only be confirmed by culture ignores the approximately 50% of cases clinically consistent with bacterial keratitis in which investigations are negative. The aetiology of these culture-negative cases is unknown. Currently, the estimation of bacterial susceptibility to antimicrobials is based on data from systemic administration and achievable serum or tissue concentrations, rather than relevant corneal concentrations and biological activity in the cornea. The provision to the clinician of minimum inhibitory concentrations of the antimicrobials for the isolated bacteria would be an important step forward. An increase in the prevalence of antimicrobial resistance is a concern, but the effect this has on disease outcomes is yet unclear. Virulence factors are not routinely assessed although they may affect the pathogenicity of bacteria within species and affect outcomes. New technologies have been developed to detect and kill bacteria, and their application to bacterial keratitis is discussed. In this review we present the multiple areas of clinical uncertainty that hamper research and the clinical management of bacterial keratitis, and we address some of the assumptions and dogma that have become established in the literature.

Foundational concepts in the biology of bacterial keratitis

Bacterial infections of the cornea, or bacterial keratitis (BK), are notorious for causing rapidly fulminant disease and permanent vision loss, even among treated patients. In the last sixty years, dramatic upward trajectories in the frequency of BK have been observed internationally, driven in large part by the commercialization of hydrogel contact lenses in the late 1960s. Despite this worsening burden of disease, current evidence-based therapies for BK - including broad-spectrum topical antibiotics and, if indicated, topical corticosteroids - fail to salvage vision in a substantial proportion of affected patients. Amid growing concerns of rapidly diminishing antibiotic utility, there has been renewed interest in urgently needed novel treatments that may improve clinical outcomes on an individual and public health level. Bridging the translational gap in the care of BK requires the identification of new therapeutic targets and rational treatment design, but neither of these aims can be achieved without understanding the complex biological processes that determine how bacterial corneal infections arise, progress, and resolve. In this chapter, we synthesize the current wealth of human and animal experimental data that now inform our understanding of basic BK pathophysiology, in context with modern concepts in ocular immunology and microbiology. By identifying the key molecular determinants of clinical disease, we explore how novel treatments can be developed and translated into routine patient care.

Late onset of microbial keratitis after laser in situ keratomileusis surgery: case series

PURPOSE

To report predisposing factors, clinical features, microbiology spectrum, antibiotic resistance, antimicrobial therapy, and outcomes of patients with a previous laser in situ keratomileusis (LASIK) surgery and diagnosed with presumed microbial keratitis.

SETTING

Sydney Eye Hospital, Sydney, New South Wales, Australia.

DESIGN

Retrospective case review.

METHODS

Patients were identified from pathology and hospital coding data from 2012 to 2016. Inclusion criteria were all patients with a previous LASIK surgery, a presumed diagnosis of microbial keratitis, and a corneal scrape performed and aged older than 18 years. Demographics, clinical details, and outcomes were collated from the medical records.

RESULTS

Sixteen patients were included, with median age of 41.5 years (range 22 to 85 years) and 56.2% of women. The median time between LASIK procedure and microbial keratitis presentation was 38.3 months (interquartile range 6.7 to 77.45 months). Cultures were positive for bacteria in 12 (75%) of 16 scrapes. Of the bacterial isolates, 12 (85.7%) were gram-positive and 2 (14.3%) gram-negative. Sensitivity profiles for the isolated bacteria were similar between fortified antibiotics (cefalotin and gentamicin) and commercial products (chloramphenicol and ofloxacin). Complications included the need for tectonic grafts, nonhealing epithelial defects, thinning, and neovascularization.

CONCLUSIONS

Late onset of keratitis after LASIK can occur with no positive cultures for nontuberculous mycobacteria, no interface involvement, and no other usual features reported in case series of infectious keratitis in LASIK patients. It has a similar clinical course to non-LASIK keratitis, such that the surgery may not have been a risk factor for infection.

Postrefractive infectious keratitis: prevention, diagnosis, management, and prognosis

PURPOSE OF REVIEW

Improve outcomes from an elective procedure by preventing a rare but sight-threatening complication.

RECENT FINDINGS

Advancement in anti-infective prophylaxis, and therefore shift in the causative organism permits better diagnostic and empiric management.

SUMMARY

Infectious keratitis presents in different patterns depending on the refractive procedure. Atypical causative organisms may respond poorly to empiric therapy and impair vision. Therefore, microbial identification is of utmost importance and therapy is adjusted accordingly.

Keratitis following laser refractive surgery: Clinical spectrum, prevention and management

Laser refractive surgery (LRS) is one of the most demanding areas of ophthalmic surgery and high level of precision is required to meet outcome expectations of patients. Post-operative recovery is of vital importance. Keratitis occurring after LRS can delay visual recovery. Both surface ablations [Photorefractive keratectomy (PRK)] as well as flap procedures [Laser in-situ keratomileusis (LASIK)/Small incision lenticule extraction] are prone to this complication. Reported incidence of post-LRS infectious keratitis is between 0% and 1.5%. The rate of infections after PRK seems to be higher than that after LASIK. Staphylococci, streptococci, and mycobacteria are the common etiological organisms. About 50–60% of patients present within the first week of surgery. Of the non-infectious keratitis, diffuse lamellar keratitis (DLK) is the most common with reported rates between 0.4% and 4.38%. The incidence of DLK seems to be higher with femtosecond LASIK than with microkeratome LASIK. A lot of stress is laid on prevention of this complication through proper case selection, asepsis, and use of improved protocols. Once keratitis develops, the right approach can help resolve this condition quickly. In cases of suspected microbial keratitis, laboratory identification of the organism is important. Most lesions resolve with medical management alone. Interface irrigation, flap amputation, collagen cross-linking and therapeutic penetrating keratoplasty (TPK) are reserved for severe/non-resolving cases. About 50–75% of all infectious keratitis cases post LRS resolve with a final vision of 20/40 or greater. Improved awareness, early diagnosis, and appropriate intervention can help limit the damage to cornea and preserve vision.

Investigating hospital Mycobacterium chelonae infection using whole genome sequencing and hybrid assembly

Mycobacterium chelonae is a rapidly growing nontuberculous mycobacterium that is a common cause of nosocomial infections. Here we describe investigation of a possible nosocomial transmission of M. chelonae at the Hospital of the University of Pennsylvania (HUP). M. chelonae strains with similar high-level antibiotic resistance patterns were isolated from two patients who developed post-operative infections at HUP in 2017, suggesting a possible point source infection. The isolates, along with other clinical isolates from other patients, were sequenced using the Illumina and Oxford Nanopore technologies. The resulting short and long reads were hybrid assembled into draft genomes. The genomes were compared by quantifying single nucleotide variants in the core genome and assessed using a control dataset to quantify error rates in comparisons of identical genomes. We show that all M. chelonae isolates tested were highly dissimilar, as indicated by high pairwise SNV values, consistent with environmental acquisition and not a nosocomial point source. Our control dataset determined a threshold for evaluating identity between strains while controlling for sequencing error. Finally, antibiotic resistance genes were predicted for our isolates, and several single nucleotide variants were identified that have the potential to modulated drug resistance.

Nontubercular Mycobacteria Associated Uveitis in HIV Positive Patients

PURPOSE

To report clinical features and outcomes of nontuberculous mycobacteria (NTM) presenting as uveitis in HIV positive patients.

MATERIALS AND METHODS

Retrospective study of HIV positive patients who were diagnosed as uveitis due to NTM.

RESULTS

Six eyes of four HIV positive patients with NTM were studied. Average age at presentation was 35.5 years (range 30-38). With specific PCR primers, Mycobacterium avium was detected in three patients (75%) and Mycobacterium fortuitum in one patient (25%). Culture was positive in two cases. Two eyes (33.33%) each had endophthalmitis and necrotizing retinitis like picture, one eye (16.66%) each had chorioretinitis and frosted branch angitis like. Visual acuity improved in two eyes (33.33%), worsened in three eyes (50%), and remained unchanged in one eye (16.6%).

CONCLUSIONS

NTM infection is a unique entity in immunosuppressed with poor visual outcome. PCR forms a useful tool for rapid diagnosis and timely initiation of specific anti-tuberculosis therapy.

Traumatic laser in situ keratomileusis flap dislocation with epithelial ingrowth, Propionibacterium acnes infection, and diffuse lamellar keratitis: A case report

RATIONALE

Traumatic flap dislocation might occur anytime after laser in situ keratomileusis (LASIK), but it is rarely concomitantly complicated with epithelial ingrowth, infectious keratitis, and diffuse lamellar keratitis altogether. Here we report a case of traumatic LASIK flap inversion with epithelial ingrowth, Propionibacterium acnes infection, and diffuse lamellar keratitis.

PATIENT CONCERNS

A 42-year-old man receiving bilateral LASIK surgery 10 years ago complained of right eye pain for 6 days after twig injury. Temporal flap inversion with epithelial ingrowth and dense infiltration at the interface were noted.

DIAGNOSES

Traumatic LASIK flap inversion with epithelial ingrowth, Propionibacterium acnes infection and diffuse lamellar keratitis.

INTERVENTIONS

Removal of corneal epithelium around the flap inversion site, flap lifting, scraping of epithelial ingrowth, removal of the dense infiltrate, alcohol soaking, interface irrigation with antibiotics, and flap reposition were performed. Diffuse lamellar keratitis was noted postoperatively. Culture of the infiltrate revealed P acnes. The infiltrate subsided and the cornea cleared up under topical antibiotics and steroid.

OUTCOMES

The visual acuity returned to 20/20. No recurrent epithelial ingrowth or infiltrate was noted during the follow-up.

LESSONS

This is the first report of Propionibacterium acnes keratitis after traumatic flap inversion. Although epithelial ingrowth, infectious keratitis, and diffuse lamellar keratitis all developed after the flap inversion, early recognition and proper intervention lead to a good result without sequels.

Diagnosis of Mycobacterium abscessus/chelonae complex cutaneous infection: Correlation of tissue culture and skin biopsy

Mycobacterium abscessus and M. chelonae belong to the rapid-growing nontuberculous mycobacteria (NTM) group, which are defined by their ability to form visible colonies on agar within 7 days of subculture. Cutaneous infections by this complex show a heterogeneous clinical presentation with varied histopathologic findings. However, the presence of vacuoles in many specimens has been reported as a specific histologic finding. Herein, we correlate the histopathology of patients with tissue-culture positive M. abscessus/M. chelonae complex in order to identify features that may prompt a rapid categorization of the infectious etiology. The cohort includes 33 skin punch biopsy specimens from 28 patients who had associated positive tissue cultures. The most frequent clinical presentation was a single or multiple nodule. Twenty-seven specimens (81.81%) were found to have vacuoles. The observation of certain histologic features (ie, polymorphonuclear microabscesses and epithelioid granuloma formation) should raise the possibility of infection by NTM. In addition to these findings, we believe the presence of vacuoles in the dermal and subcutaneous inflammation should raise suspicion for NTM.

Transient extremely shallow anterior chamber caused by ciliochoroidal detachment in a patient with Mycobacterium chelonae keratitis

Purpose

To report a case of Mycobacterium chelonae keratitis that resulted in a transient reduction of anterior chamber depth.

Observations

A 46-year-old man with keratoconus and reduced visual acuity (20/286) in his left eye presented with ciliary injection 16 months after femtosecond laser-assisted penetrating keratoplasty (PK). A slit-lamp examination showed a corneal ulcer with infiltrates and edema in both the host and graft between the 3 o'clock and 6 o'clock positions. Microbiologic tests confirmed the presence of M. chelonae. Topical arbekacin and moxifloxacin, erythromycin/colistin ointment, and oral clarithromycin were prescribed. We monitored anterior chamber depth by anterior segment optical coherence tomography (AS-OCT) throughout the recovery period. The anterior chamber depth was normal before treatment, with an intraocular pressure (IOP) of 7 mmHg. Although ciliary injection and infiltrates were gradually resolved, slit-lamp examination and AS-OCT revealed an extreme reduction of anterior chamber depth without corneal perforation, 1 month after beginning treatment. The IOP was 5 mmHg, and ciliochoroidal detachment (CCD) was present. The anterior chamber increased with the resolution of CCD and keratitis. Although hypotony continued despite the resolution of CCD and keratitis, the IOP eventually recovered to ≥10 mmHg at 1 month after remission. Onset and resolution of transient reduction of anterior chamber depth presumably occurred by anterior rotation and recovery of the ciliary body, respectively. Subsequent PK triple surgery enabled visual recovery to 20/100.

Conclusions and importance

severe anterior segment inflammation due to infectious keratitis may cause CCD and subsequent reduction of anterior chamber depth due to anterior rotation. AS-OCT is a non-invasive and efficient tool for the evaluation of iridociliary structure and the anterior chamber in patients with infectious keratitis.

Antiangiogenesis Effect of Albendazole on the Cornea

Purpose: To investigate the anti-(lymph)angiogenic and anti-inflammatory effects of albendazole and to study whether these effects are additive with bevacizumab therapy in a murine corneal suture model. Methods: Corneal neovascularization (NV) and lymphangiogenesis (LY) were compared in a corneal suture model after administration of a subconjunctival injection of albendazole, bevacizumab, dexamethasone, or phosphate-buffered saline (PBS). Immunohistochemical staining and analysis were performed in each group. Real-time polymerase chain reaction (RT-PCR) was performed to quantify the expression of inflammatory cytokines (tumor necrosis factor [TNF]-alpha and interleukin-6), vascular endothelial growth factor (VEGF)-A, VEGF-C, vascular endothelial growth factor receptor (VEGFR)-2, and VEGFR-3. To evaluate the additive effect of albendazole, corneal NV and LY were also analyzed in a combined group of albendazole and bevacizumab therapy and the additive effect was compared with that in the group of double dose of bevacizumab. Results: The albendazole group showed less NV and less LY compared with the PBS control group (P < 0.01). When albendazole was combined with bevacizumab therapy, a significant decrease in NV and LY was seen compared with bevacizumab treatment alone, and with albendazole alone (all P values <0.05). The combination group showed better antilymphangiogenesis effect than the group of double dose bevacizumab. The albendazole-treated group showed reduced expression of VEGF-A, VEGF-C, TNF-alpha, and VEGFR-2 compared with corneas from the PBS group (P value <0.05 in all respective comparisons). Conclusion: Albendazole significantly decreased NV and LY in the cornea. This beneficial effect is additively enhanced when combined with bevacizumab treatment.

Identification of the Infection Source of an Outbreak of Mycobacterium Chelonae Keratitis After Laser in Situ Keratomileusis

PURPOSE

Nontuberculous mycobacteria keratitis is a rare but challenging complication of laser in situ keratomileusis (LASIK). This study was conducted to determine the source(s) of infection in a cluster of cases of keratitis after LASIK and to describe this outbreak and patients' outcomes.

METHODS

In this retrospective, case series, single-center study, 86 patients were included who underwent LASIK or photorefractive keratectomy between December 2011 and February 2012. Corneal scrapes from the affected eyes, samples of tap and distilled water, water from the reservoir of the distilling equipment, steamer, and autoclave cassette; antiseptic and anesthetic solutions and surgical instrument imprints were cultivated in liquid and on solid media. Gram-negative bacteria and yeasts were identified using automated systems and mycobacteria by polymerase chain reaction-restriction enzyme analysis of the hsp65 gene (PRA-hsp65) and DNA sequencing. Mycobacterial isolates were typed by pulsed-field gel electrophoresis. The cases and outcomes are described. The main outcome measure was identification of the source(s) of the mycobacterial infections.

RESULTS

Eight (15 eyes) of 86 patients (172 eyes) who underwent LASIK developed infections postoperatively; no patients who underwent photorefractive keratectomy developed infections. Mycobacterium chelonae was isolated from 4 eyes. The distilled water collected in the surgical facility contained the same M. chelonae strain isolated from the patients' eyes. Different gram-negative bacteria and yeasts were isolated from samples collected at the clinic but not from the patients' eyes.

CONCLUSIONS

Tap water distilled locally in surgical facilities may be a source of infection after ocular surgery and its use should be avoided.

Mycobacterium Chelonae Keratitis in a Patient with SjöGren's Syndrome

Purpose

In this report a case of Mycobacterium chelonae keratitis in a patient without any previously described risk factors is described. The only risk factor found was a rheumatoid arthritis related Sjögren's syndrome.

Methods

Case report.

Results

A 60-year-old woman was referred to the hospital with an infectious keratitis of the left eye of 3 months duration, unresponsive to empirical therapy with ofloxacin and tobramycin drops. Her medical history included a longstanding rheumatoid arthritis and a secondary ocular surface syndrome. Upon arrival the left eye showed diffuse corneal edema and centrally several large infiltrates with fluffy edges, surrounded by several smaller satellite infiltrates. The cornea was scraped for culture and grew M chelonae and sensitivity testing showed sensitivity to ciprofloxacin, clofazimine, and clarithromycin. Systemically ciprofloxacin 750 mg and clarithromycin 500 mg twice daily were prescribed orally. Topical therapy consisted of topical erythromycin 10 mg/mL and ofloxacin 3 mg/mL every 2 hours. Treatment was continued for a total of 10 months during which the infiltrates cleared completely, but the central cornea remained scarred.

Conclusions

M chelonae can be a cause of infectious keratitis in patients without known risk factors for rapidly growing mycobacterium keratitis. Especially in the case of ocular infections that show no response to regular antibacterial treatment, mycobacterial infection should be considered. Good communication between the ophthalmologist and the microbiologist is crucial for a rapid diagnosis.

Bilateral Mycobacterium chelonae Keratitis after Phacoemulsification Cataract Surgery

The purpose of this manuscript is to report the case of an 81-year-old patient who presented with bilateral keratitis after phacoemulsification surgery. Cultures came back positive for Mycobacterium chelonae. Despite aggressive topical and systemic antimicrobial treatment, the patient developed a corneal perforation in both eyes, treated with corneal glue in the right eye and corneoscleral patch in the left eye. After two years of follow-up, patient was free of infection in the right eye with visual acuity of 20/200 and the left eye progressed to phthisis bulbi. We present an unusual case of bilateral Mycobacterium chelonae keratitis associated with phacoemulsification cataract surgery. This case represents the importance of making clinicians aware of this devastating infection and highlights the need for better management to improve outcomes.

Delayed onset Mycobacterium intracellulare keratitis after laser in situ keratomileusis: A case report and literature review

RATIONALE

Infectious keratitis is a relatively uncommon but potentially sight-threatening complication of laser in situ keratomileusis (LASIK). Mycobacterial keratitis is usually regarded as late onset keratitis among post-LASIK keratitis. There has been no documented case of Mycobacterium intracellulare post-LASIK keratitis of a long-latent period.

PATIENT CONCERNS

A 36-year-old man was referred to our out-patient clinic, for persistent corneal epithelial defect with intrastromal infiltration. He had undergone uneventful bilateral LASIK procedure 4 years before. He complained decreased vision, accompanied by ocular pain, photophobia, and redness in his left eye for 7 months.

DIAGNOSIS

Lamellar keratectomy was taken using femtosecond laser. Bacterial culture with sequenced bacterial 16s ribosomal DNA confirmed the organism to be M intracellulare.

INTERVENTIONS

After 3 months of administration of topical clarithromycin, amikacin, and moxifloxacin, the corneal epithelial defect was resolved and the infiltration was much improved. However, newly developed diffuse haziness with surrounding granular infiltration in the central cornea was noted. Drug toxicity was suspected and topical moxifloxacin was discontinued, resulting in resolution of the diffuse haze with infiltration.

OUTCOME

The patient was followed up regularly without medication thereafter and recurrence was not found for 7 years.

LESSONS

This case presents the first case of M intracellulare keratitis after LASIK. LASIK surgeons should aware that post-LASIK keratitis can develop long after the operation and careful suspicion of infectious disease with meticulous diagnostic test is needed.

Discovery of novel antimycobacterial drug therapy in biofilm of pathogenic nontuberculous mycobacterial keratitis

PURPOSE

The potential of slow-growing mycobacteria to form biofilms in human tissues contributes to the problem of establishing an effective treatment strategy. The purpose of this study was to examine new antibiotic strategies to enhance current treatment options for these infections.

METHODS

Sensitivities of Mycobacterium fortuitum ATCC 49404 and Mycobacterium chelonae ATCC 35752 were evaluated for different antimicrobials singly and in combination using broth microdilution and FICI (Fractional Inhibitory Concentration Index) synergy screening. Anti-biofilm effects were evaluated in an 8-well chamber slide biofilm model. The efficacy of a new treatment strategy was validated using the novel neutropenic mouse keratitis model and monitored by slit-lamp microscopy, confocal microscopy, and colony forming unit measurements.

RESULTS

We reported the very first evidence that these organisms develop corneal biofilms by the accumulation of extracellular DNA (eDNA) and the presence of microcolonies using a novel mycobacterial neutropenic mouse keratitis model. The combination of amikacin and gatifloxacin or besifloxacin was more effective than the current gold-standard drug, amikacin, and we developed a novel treatment strategy (amikacin + gatifloxacin + DNase), the destruction of biofilm matrix component, eDNA, which increased the efficacy of the new antibiotic combination for treating mycobacterial infection in in vitro (P = 0.002) and in vivo (P = 0.001) compared to its respective control.

CONCLUSION

Biofilms have a role in mycobacterial keratitis leading to poor treatment outcomes in clinical practice and the use of combination therapy (amikacin + gatifloxacin + DNase) could be a useful new treatment option.

An unusual case of spontaneous Mycobacterium chelonae corneal ulcer in a healthy middle-aged adult

Background

To report a rare presentation of culture-positive Mycobacterium chelonae corneal ulcer and its management.

Findings

We report a rare case of a patient with a history of chronic pain and blurriness of vision. Examination revealed a chronic nonhealing paracentral corneal ulcer inferiorly at the 5–7 o’clock meridian with anterior chamber reaction unresponsive to routine antibiotic and antifungal medications with Mantoux test positivity in a middle-aged nondiabetic patient with no prior history of trauma, ocular surgery, and contact lens usage. Ziehl–Neelsen staining of the nonhealing ulcer revealed acid-fast bacilli typical of M. chelonae, with subsequent culture positivity in Löwenstein–Jensen medium. Subsequent treatment with topical fortified amikacin and tobramycin resulted in rapid healing of the corneal ulcer.

Conclusion

M. chelonae presenting as a chronic nonhealing corneal ulcer spontaneously occurring in a healthy adult with no predisposing factor draws attention towards the need to have a good index of suspicion by performing a Ziehl–Neelsen stain and culture, and subsequent successful management with topical fortified amikacin and tobramycin.

An Unusual Case of Nonhealing Granulomatous Keratitis Caused by Mycobacterium chelonae in a Healthy Middle Aged Adult

Purpose. To report a rare presentation of culture positive Mycobacterium chelonae (M. chelonae) corneal ulcer and its management. Case Report. We report a rare case with history of chronic pain and blurriness of vision. Examination revealed chronic nonhealing paracentral corneal ulcer inferiorly at 5 to 7 o'clock meridian with anterior chamber cells 1+ unresponsive to routine antibiotic and antifungal medications with Mantoux test (MT) positivity in a middle aged nondiabetic patient with no prior obvious history of trauma, ocular surgery, and contact lens usage. Discussion. Ziehl Neelsen (ZN) staining in nonhealing ulcer revealed acid fast bacilli typical of M. chelonae with subsequent culture positivity in Lowenstein Jensen (LJ) medium. Subsequent treatment with topical fortified amikacin and tobramycin resulted in rapid healing of corneal ulcer. Conclusion. M. chelonae presenting as a chronic nonhealing corneal ulcer spontaneously occurring in a healthy young adult with no predisposing factor draws the need to have a good index of suspicion by performing ZN stain and culture and its subsequent successful management with topical fortified amikacin and tobramycin.

The looming tide of nontuberculous mycobacterial infections in Portugal and Brazil

Nontuberculous mycobacteria (NTM) are widely disseminated in the environment and an emerging cause of infectious diseases worldwide. Their remarkable natural resistance to disinfectants and antibiotics and an ability to survive under low-nutrient conditions allows NTM to colonize and persist in man-made environments such as household and hospital water distribution systems. This overlap between human and NTM environments afforded new opportunities for human exposure, and for expression of their often neglected and underestimated pathogenic potential. Some risk factors predisposing to NTM disease have been identified and are mainly associated with immune fragilities of the human host. However, infections in apparently immunocompetent persons are also increasingly reported. The purpose of this review is to bring attention to this emerging health problem in Portugal and Brazil and to emphasize the urgent need for increased surveillance and more comprehensive epidemiological data in both countries, where such information is scarce and seriously thwarts the adoption of proper preventive strategies and therapeutic options.

Comparison of the Anti-angiogenic and Anti-inflammatory Effects of Two Antibiotics: Clarithromycin Versus Moxifloxacin

PURPOSE

Clarithromycin is a 14-membered ring macrolide antibiotic with anti-inflammatory as well as antibacterial activity, and has been used worldwide. Moxifloxacin is a leading fourth generation quinolone antibiotic that has been used worldwide perioperatively. We intended to evaluate whether clarithromycin can suppress angiogenesis and inflammation in the cornea, and to compare the anti-inflammatory and anti-angiogenic effects of the two antibiotics, clarithromycin and moxifloxacin.

METHODS

We made a murine corneal suture model and tested the anti-inflammatory and anti-angiogenic effects of clarithromycin (5 mg/ml) and moxifloxacin (5 mg/ml) in two randomly divided groups. Dexamethasone (5 mg/ml) was used as a positive control. After making two sutures on the cornea, we performed subconjunctival injections (10 μl) on each group on the day of suture, and every day thereafter until the 8th day post-suture. After harvesting corneas on the 8th post-suture day for immunohistochemical staining, we compared neovascularization (NV), lymphangiogenesis (LY) and inflammatory cell infiltration among the groups.

RESULTS

Clarithromycin suppressed NV, LY and inflammatory infiltration, compared with phosphate-buffered saline (PBS). However, moxifloxacin did not suppress NV, LY, or inflammatory infiltration, compared with PBS. Comparison between clarithromycin and moxifloxacin, clarithromycin showed a tendency of decreasing LY (p = 0.063) and had less inflammatory cell infiltration (p < 0.05) than did the moxifloxacin group. The anti-(lymph)angiogenic and anti-inflammatory effects of clarithromycin were as high as those of dexamethasone.

CONCLUSION

Clarithromycin suppressed LY and inflammation in the cornea, and its anti-inflammatory effect was significantly superior to that of moxifloxacin.

Use of Topical Besifloxacin in the Treatment of Mycobacterium chelonae Ocular Surface Infections

PURPOSE

To present the clinical outcome of 3 cases of ocular surface infections by Mycobacterium chelonae treated with besifloxacin (0.6%, Besivance; Bausch & Lomb, Tampa, FL).

METHODS

In this retrospective review of a small case series, we reviewed the medical records of 3 clinical patients with M. chelonae infection involving the ocular surface. Besifloxacin was used as an adjunct in 2 cases of keratitis and as the principal therapeutic agent in a case of nodular conjunctivitis.

RESULTS

Two patients who presented with culture-proven M. chelonae keratitis initially had been treated with topical amikacin and oral clarithromycin for 6 months in the first case and for 2 months in the second without complete resolution. Topical besifloxacin was added as an adjunct therapy to amikacin with progressive weaning of clarithromycin. Both cases of keratitis eventually resolved without recurrence after discontinuation of topical amikacin and besifloxacin. A third patient presented with nodular conjunctival inflammation, which initially had been treated with topical ciprofloxacin and corticosteroids without improvement. One nodular lesion was excised and submitted for microbial culture, which revealed the growth of M. chelonae. Marked improvement of the conjunctivitis was noted after 3 weeks of treatment with topical besifloxacin. Complete resolution of the conjunctival nodules was achieved after 10 weeks of treatment with besifloxacin.

CONCLUSIONS

Topical besifloxacin seems to be a useful adjunct agent in the treatment of nontuberculous mycobacterial keratitis by M. chelonae and may be viable for use as a first-line agent in cases of nodular conjunctivitis by M. chelonae.

Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature

Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.

Nosocomial rapidly growing mycobacterial infections following laparoscopic surgery: CT imaging findings

OBJECTIVE

To identify the distribution and frequency of computed tomography (CT) findings in patients with nosocomial rapidly growing mycobacterial (RGM) infection after laparoscopic surgery.

METHOD

A descriptive retrospective study in patients with RGM infection after laparoscopic surgery who underwent CT imaging prior to initiation of therapy. The images were analyzed by two radiologists in consensus, who evaluated the skin/subcutaneous tissues, the abdominal wall, and intraperitoneal region separately. The patterns of involvement were tabulated as: densification, collections, nodules (≥1.0 cm), small nodules (<1.0 cm), pseudocavitated nodules, and small pseudocavitated nodules.

RESULTS

Twenty-six patients met the established criteria. The subcutaneous findings were: densification (88.5%), small nodules (61.5%), small pseudocavitated nodules (23.1 %), nodules (38.5%), pseudocavitated nodules (15.4%), and collections (26.9%). The findings in the abdominal wall were: densification (61.5%), pseudocavitated nodules (3.8%), and collections (15.4%). The intraperitoneal findings were: densification (46.1%), small nodules (42.3%), nodules (15.4%), and collections (11.5%).

CONCLUSION

Subcutaneous CT findings in descending order of frequency were: densification, small nodules, nodules, small pseudocavitated nodules, pseudocavitated nodules, and collections. The musculo-fascial plane CT findings were: densification, collections, and pseudocavitated nodules. The intraperitoneal CT findings were: densification, small nodules, nodules, and collections.

KEY POINTS

• Rapidly growing mycobacterial infection may occur following laparoscopy. • Post-laparoscopy mycobacterial infection CT findings are densification, collection, and nodules. • Rapidly growing mycobacterial infection following laparoscopy may involve the peritoneal cavity. • Post-laparoscopy rapidly growing mycobacterial intraperitoneal infection is not associated with ascites or lymphadenopathy.

Localized cutaneous infections in immunocompetent individuals due to rapidly growing mycobacteria

Rapidly growing mycobacteria (RGM) cause skin infections that are refractory to standard antibiotic regimens. Although typically associated with disseminated cutaneous or other systemic infections in immunocompromised patients, RGM sometimes cause localized cutaneous infections in immunocompetent hosts. These infections are almost always associated with precedent skin trauma and inoculation, and therefore have been implicated in outbreaks involving contaminated tattoo ink and inadequately sterilized acupuncture needles. Histologic features often include suppurative granulomatous inflammation, and microorganisms are rarely visualized with stains for acid-fast bacilli. The differential diagnosis includes granulomatous fungal and non-RGM bacterial infections as well as noninfectious suppurative or sarcoidlike conditions. Because no pathognomonic histologic features exist for cutaneous RGM infections, clinical suspicion and appropriate workup are essential to reach an accurate and timely diagnosis. Most localized cutaneous RGM infections in immunocompetent individuals respond well to either clarithromycin or amikacin, in combination with surgical debridement.

Multilocus sequence typing scheme versus pulsed-field gel electrophoresis for typing Mycobacterium abscessus isolates

Outbreaks of infections by rapidly growing mycobacteria following invasive procedures, such as ophthalmological, laparoscopic, arthroscopic, plastic, and cardiac surgeries, mesotherapy, and vaccination, have been detected in Brazil since 1998. Members of the Mycobacterium chelonae-Mycobacterium abscessus group have caused most of these outbreaks. As part of an epidemiological investigation, the isolates were typed by pulsed-field gel electrophoresis (PFGE). In this project, we performed a large-scale comparison of PFGE profiles with the results of a recently developed multilocus sequence typing (MLST) scheme for M. abscessus. Ninety-three isolates were analyzed, with 40 M. abscessus subsp. abscessus isolates, 47 M. abscessus subsp. bolletii isolates, and six isolates with no assigned subspecies. Forty-five isolates were obtained during five outbreaks, and 48 were sporadic isolates that were not associated with outbreaks. For MLST, seven housekeeping genes (argH, cya, glpK, gnd, murC, pta, and purH) were sequenced, and each isolate was assigned a sequence type (ST) from the combination of obtained alleles. The PFGE patterns of DraI-digested DNA were compared with the MLST results. All isolates were analyzable by both methods. Isolates from monoclonal outbreaks showed unique STs and indistinguishable or very similar PFGE patterns. Thirty-three STs and 49 unique PFGE patterns were identified among the 93 isolates. The Simpson's index of diversity values for MLST and PFGE were 0.69 and 0.93, respectively, for M. abscessus subsp. abscessus and 0.96 and 0.97, respectively, for M. abscessus subsp. bolletii. In conclusion, the MLST scheme showed 100% typeability and grouped monoclonal outbreak isolates in agreement with PFGE, but it was less discriminative than PFGE for M. abscessus.

Ocular penetration and pharmacokinetics of topical clarithromycin eye drops to rabbits

PURPOSE

To evaluate the ocular pharmacokinetics of clarithromycin (CLA) eye drops topically applied to the corneas of rabbits.

METHODS

One 50-μL drop of CLA (0.25%) was administered to each New Zealand white rabbit in a single dose group, and one 50-μL drop of CLA was administered 6 times at 5-min intervals to each rabbit in a loading dose group. The effect of debridement on corneal penetration was also investigated in a de-epithelium group. The drug concentrations in the cornea and aqueous humor (AH) were assayed using high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS) analysis.

RESULTS

Maximum CLA levels were achieved in the corneas and AH at 15 and 60 min, respectively, in the intact epithelium eyes in the single dose group (24.54±10.64 μg/g and 0.78±0.22 μg/mL, respectively, mean±the standard error of the mean, n=8). In the loading dose group, 30 min after the last application, the CLA level in the corneas reached 92.26±17.62 μg/g. In the loading dose group, the drug levels in the corneas and AH were significantly increased compared with the drug levels in the corneas with the intact epithelium and de-epithelium eyes in the single dose group at the corresponding time points (P<0.05). The estimated CLA half-lives in the corneas and AH for the intact eyes were 103.28 and 132.61 min, respectively.

CONCLUSION

Therapeutic CLA levels can be achieved in rabbit corneas after topically applying the drug with eye drops.

Riboflavin/UVA Photochemical Therapy for Severe Infectious Keratitis

Purpose

To describe the antibacterial activity of treatment with riboflavin and ultraviolet A light (UVA) in cases of severe infectious keratitis.

Methods

A retrospective analysis was performed of an interventional case series in which 6 eyes of 6 patients with severe infectious keratitis, all of whom were refractive to multidrug conventional therapy, were treated with riboflavin/UVA. The procedure was conducted according to the standardized protocol of corneal collagen crosslinking (CXL) for keratoconus. Best spectacle-corrected visual acuity and clinical outcomes were evaluated before and during the follow-up period.

Results

Five of the 6 patients showed rapid reduction in symptoms and decreased infiltrate size after riboflavin/UVA photochemical therapy. Signs of infection and inflammation mostly resolved within 1 to 2 weeks after the treatment. Despite this therapy, one patient continued to deteriorate, and penetrating keratoplasty was performed.

Conclusions

The adjunctive use of riboflavin/UVA photochemical therapy has a positive effect on refractory infectious keratitis. The treatment seems to be safe and effective and should be considered as part of the first-line therapy in severe cases of infectious keratitis.

Non-tuberculous mycobacterial keratitis

Non-tuberculous mycobacteria are environmental, opportunistic pathogens that are increasingly being recognized as important causes of many human diseases. Among them, rapidly growing mycobacteria are the most notorious organisms causing infectious keratitis. Non-tuberculous mycobacterial (NTM) keratitis commonly occurs after trauma or refractive surgery, and can masquerade as fungal, herpetic or amoebic keratitis. Therefore, the diagnosis is often delayed. Prolonged medical treatment and judicious surgical debridement are required in order to eradicate the pathogens. Combination therapy with aminoglycosides, macrolides and fluoroquinolones improves the prognosis and decreases the occurrence of drug resistance. However, regardless of the development of new diagnostic techniques and antimicrobials, NTM keratitis remains a clinical challenge for most ophthalmologists. In this article, we provide a concise introduction to the epidemiological features and clinical characteristics of NTM keratitis, and the modern diagnostic tools used for it. We also summarize the current concepts of prevention and treatment for this potentially devastating condition.

Nontuberculous mycobacterial infection after clear corneal phacoemulsification cataract surgery: a report of 13 cases

PURPOSE

To review the patient profile, clinical presentation, management, and outcomes of nontuberculous mycobacterial (NTM) infection after clear corneal phacoemulsification.

METHODS

Review of consecutive cases diagnosed with NTM infection after phacoemulsification from 2004 to 2009. Demographic data, clinical characteristics, diagnosis, treatment, and outcomes were analyzed.

RESULTS

Thirteen eyes of 13 patients with mean age of 61.1 years, consisting of 7 men and 6 women were included. Twelve of 13 eyes (92%) underwent uncomplicated clear cornea phacoemulsification with posterior lens implant. Mean interval from surgery to onset of symptoms was 6.3 weeks, and time to referral ranged from 2 days to 9 months. Ten eyes (77%) presented with stromal wound abscess, whereas 3 (23%) appeared as iridocyclitis with posterior capsule plaques. Five eyes were clustered while the rest were isolated cases. All cases were culture positive for NTM. Two cases were treated medically, 3 had removal of lens implant and capsule, and 8 had penetrating keratoplasty with or without removal of lens implant, iridectomy, and/or pars plana vitrectomy. After a mean follow-up of almost 22 months, best-corrected visual acuity of 20/40 or better was achieved in half of the cases (54%). One case of recurrence was noted.

CONCLUSIONS

NTM infection should be suspected in patients presenting with corneal stromal wound abscess or iridocyclitis with posterior capsular plaques 6 to 7 weeks after phacoemulsification. Early diagnosis and treatment can lead to good outcomes, and management should include a combination of medical and surgical therapies.

Antimicrobial susceptibility of nontuberculous mycobacteria from eye infections

PURPOSE

To characterize formerly designated atypical or nontuberculous mycobacteria (NTM) associated with eye infections.

METHODS

All clinical NTM eye isolates (112 isolates from 100 patients) submitted to a single national NTM reference laboratory between 1982 and 2009 were identified using polymerase chain reaction and restriction fragment length polymorphism of the hsp65 gene. Isolates were tested against 10 antimicrobials, including besifloxacin, a new 8-chloro-fluoroquinolone. Assessments included species of NTM recovered, year of isolation, type of eye infection, geographic location, and drug susceptibilities.

RESULTS

In the 1980s, the major pathogen isolated was Mycobacterium abscessus. In the 1990 s, Mycobacterium chelonae emerged as the major pathogen. By 2000, it was responsible for more than 50% of all cases. The majority of M. abscessus and Mycobacterium fortuitum were from southern coastal states and Texas, whereas M. chelonae isolates were more widespread geographically. The most active antimicrobials were amikacin and clarithromycin/azithromycin for M. abscessus and clarithromycin/azithromycin, amikacin, and tobramycin, and the quinolones for M. chelonae.

CONCLUSIONS

This is the largest study of NTM ophthalmic isolates to date and is the first to include susceptibilities and molecular identification for all isolates studied. This series establishes M. chelonae (44%) and M. abscessus (37%) as the NTM species most frequently associated with ophthalmic infections. Topical ophthalmic fluoroquinolones may have a role in the management of ocular infections involving M. chelonae and M. fortuitum.

LASIK interface complications: etiology, management, and outcomes

PURPOSE

To describe the etiology, diagnosis, clinical course, and management of LASIK interface complications.

METHODS

Literature review.

RESULTS

Primary interface complications include infectious keratitis, diffuse lamellar keratitis, central toxic keratopathy, pressure-induced stromal keratopathy (PISK), and epithelial ingrowth. Infectious keratitis is most commonly caused by Methicillin-resistant Staphylococcus aureus (early onset) or atypical Mycobacterium (late onset) postoperatively, and immediate treatment includes flap lift and irrigation, cultures, and initiation of broad-spectrum topical antibiotics, with possible flap amputation for recalcitrant cases. Diffuse lamellar keratitis is a white blood cell infiltrate that appears within the first 5 days postoperatively and is acutely responsive to aggressive topical and oral steroid use in the early stages, but may require flap lift and irrigation to prevent flap necrosis if inflammation worsens. In contrast, PISK is caused by acute steroid response and resolves only with cessation of steroid use and intraocular pressure lowering. Without appropriate therapy PISK can result in severe optic nerve damage. Central toxic keratopathy mimics stage 4 diffuse lamellar keratitis, but occurs early in the postoperative period and is noninflammatory. Observation is the only effective treatment, and flap lift is usually not warranted. Epithelial ingrowth is easily distinguishable from other interface complications and may be self-limited or require flap lift to treat irregular astigmatism and prevent flap melt.

CONCLUSIONS

Differentiating between interface entities is critical to rapid appropriate diagnosis, treatment, and ultimate visual outcome. Although initial presentations may overlap significantly, the conditions can be readily distinguished with close follow-up, and most complications can resolve without significant visual sequelae when treated appropriately.

Identification of nontuberculous mycobacteria isolated from clinical sterile sites in patients at a university hospital in the city of Rio de Janeiro, Brazil

OBJECTIVE

To identify nontuberculous mycobacteria (NTM) isolated from sterile sites in patients hospitalized between 2001 and 2006 at the Clementino Fraga Filho University Hospital, located in the city of Rio de Janeiro, Brazil.

METHODS

During the study period, 34 NTM isolates from sterile sites of 14 patients, most of whom were HIV-positive, were submitted to phenotypic identification and hsp65 PCR-restriction enzyme analysis (PRA).

RESULTS

Most isolates were identified as Mycobacterium avium, followed by M. monacense, M. kansasii, and M. abscessus.

CONCLUSIONS

The combination of PRA, a relatively simple and inexpensive method, with the evaluation of a few phenotypic characteristics can allow NTM to be accurately identified in the routine of clinical laboratories.

Antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria

Within the past 10 years, treatment and diagnostic guidelines for nontuberculous mycobacteria have been recommended by the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA). Moreover, the Clinical and Laboratory Standards Institute (CLSI) has published and recently (in 2011) updated recommendations including suggested antimicrobial and susceptibility breakpoints. The CLSI has also recommended the broth microdilution method as the gold standard for laboratories performing antimicrobial susceptibility testing of nontuberculous mycobacteria. This article reviews the laboratory, diagnostic, and treatment guidelines together with established and probable drug resistance mechanisms of the nontuberculous mycobacteria.

Antibacterial activity and cytotoxicity analysis of halistanol trisulphate from marine sponge Petromica citrina

OBJECTIVES

An aqueous extract and fraction from the marine sponge Petromica citrina have antibacterial activity. We performed a chemical and biological characterization of the antibiotic substance from P. citrina and investigated its mode of action on Staphylococcus aureus cells.

METHODS

The inhibitory activity of the aqueous extract of P. citrina was determined against 14 bacteria belonging to type strains and clinical antibiotic-resistant strains. The aqueous extract was fractionated under bioassay guidance and the bioactive substance was identified by its (1)H-NMR, (13)C-NMR and mass spectra. The MIC and the MBC of this substance were determined. This substance was also subjected to cytotoxic bioassays. The mode of action on S. aureus cells was investigated by light and transmission electron microscopy analysis.

RESULTS

P. citrina showed a large spectrum of activity against type strains and resistant-bacteria such as S. aureus, Staphylococcus epidermidis, Enterococcus faecalis, Mycobacterium fortuitum and Neisseria gonorrhoeae. The aqueous extract was fractionated and halistanol trisulphate (24ε,25-dimethylcholestane-2β,3α,6α-triol trisodium sulphate) was isolated for the first time from P. citrina. Halistanol trisulphate had a bactericidal effect on exponentially growing S. aureus cells at the MIC (512 mg/L). Cytotoxicity biossays showed moderate toxicity against cancer cell line L929 (fibrosarcoma). This substance apparently acts by damaging the cell membrane, with subsequent cell lysis.

CONCLUSIONS

Halistanol trisulphate is a broad-spectrum antibiotic isolated from P. citrina with a mode of action involving disruption of the cytoplasmic membrane. It is a new candidate for research on antibacterial substances.

Nontuberculous mycobacterial ocular and adnexal infections

The nontuberculous (also called "atypical") mycobacteria have become increasingly important causes of systemic as well as ocular morbidity in recent decades. All ocular tissues can become infected with these organisms, particularly in patients who are predisposed following ocular trauma, surgery, use of corticosteroids, or are immunocompromised. Because of their relative resistance to available antibiotics, multidrug parenteral therapy continues to be the mainstay of treatment of more serious ocular and adnexal infections caused by nontuberculous mycobacteria (NTM). Periocular cutaneous, adnexal, and orbital NTM infections remain rare and require surgical debridement and long-term parenteral antibiotic therapy. NTM scleritis may occur after trauma or scleral buckling and can cause chronic disease that responds only to appropriate antibiotic therapy and, in some cases, surgical debridement and explant removal. NTM infectious keratitis following trauma or refractive surgical procedures is commonly confused with other infections such as Herpes simplex keratitis and requires aggressive topical therapy and possible surgical debridement, particularly in those cases occuring after laser in situ keratomileusis. Only 18 cases of endophthalmitis due to NTM have been reported. Systemic and intraocular antibiotic therapy and multiple vitrectomies may be needed in NTM endophthalmitis; the prognosis remains poor, however. Disseminated NTM choroiditis in acquired immune deficiency syndrome patients with immune reconstitution during highly active anti-retroviral therapy is a rare infection that can present as a necrotizing chorioretinitis with dense vitritis, mimicking many other entities and needs to be recognized so that timely, life-saving treatment can be administered. Regardless of which ocular tissue is infected, all NTM ocular infections present similar challenges of recognition and of therapeutic intervention. We clarify diagnosis and delineate modern, effective therapy for these conditions.

Uveitis with occult choroiditis due to Mycobacterium kansasii: limitations of interferon-gamma release assay (IGRA) tests (case report and mini-review on ocular non-tuberculous mycobacteria and IGRA cross-reactivity)

Ocular tuberculosis is difficult to diagnose but should be suspected when uveitis fails to respond to inflammation suppressive therapy. Interferon-gamma release assays (IGRAs) represent a substantial help to diagnose suspected ocular tuberculosis especially in non-endemic areas. Indocyanine green angiography (ICGA) is able to detect clinically silent choroiditis that, when associated with a positive IGRA test, should lead the clinician to suspect ocular tuberculosis, warranting specific therapy. The fact that IGRA tests can also react with some atypical strains of mycobacteria is not always known. We report here a case with resistant post-operative inflammation that presented with occult ICGA-detected choroiditis and a positive IGRA test that was most probably due to the non-tuberculous mycobacterium (NTM) Mycobacterium kansasii. A 66 year-old man presented with a resistant cystoid macular oedema (CMO) in his left eye after combined cataract and epiretinal membrane surgery. At entry, his best-corrected visual acuity (BCVA) was 0.5 for far and near OS. Intraocular inflammation measured by laser flare photometry was elevated in the left eye (54.4 ph/ms) and also in the right eye (50.9 ph/ms). Four subTenon's injections of 40 mg of triamcinolone did not produce any substantial improvement. Therefore a complete uveitis work-up was performed. Fluorescein angiography showed CMO OS and ICGA showed numerous hypofluorescent dots and fuzziness of choroidal vessels in both eyes. Among performed laboratory tests, the QuantiFERON®-TB Gold test was positive. After a pulmonological examination disclosing a right upper lobe infiltrate, the patient was started on a triple anti-tuberculous therapy. Bronchial aspirate, obtained during bronchoscopy, was Ziehl-positive and culture grew M. kansasii. Nine months later, BCVA OS increased to 1.0 and flare decreased to 40.2 ph/ms. The CMO OS resolved angiographically and did not recur with a macula still slightly thickened on OCT. Suspected ocular tuberculosis based on clinical findings and a positive IGRA test can, in rare instances, be due to atypical mycobacteria that also produce positive IGRA tests such as M. kansasii, M. szulgai, M. gordonae, M. flavescens and M. marinum. In our case failure to isolate the atypical mycobacterium would not have had negative therapeutic consequences, as M. kansasii is sensitive to the standard anti-tuberculous treatments, which is not the case with other NTMs.

Microbial keratitis after corneal laser refractive surgery

Corneal laser refractive surgery is increasingly being performed on patients with the aim of improving unaided vision. Most candidates for surgery have excellent spectacle- or contact lens-corrected vision. Although microbial keratitis following refractive surgery is a rare complication, and usually has a good visual outcome, it can be sight-threatening. The spectrum of pathogens differs to other causes of microbial keratitis, such as contact lens-associated keratitis, and a different management approach is required. Postoperatively, patients are prescribed topical steroids and broad-spectrum topical antibiotics, typically fluoroquinolones. These do not cover unusual organisms, such as fungi, Nocardia, Acanthamoeba and some atypical mycobacteria. In post-laser-assisted in situ keratomileusis microbial keratitis, the lamellar flap should be lifted to acquire samples for specific microbiological examination, including these atypical organisms. Confocal microscopy is a noninvasive test that provides morphological information, and is operator dependent, but may assist in the rapid diagnosis of fungal, Acanthamoeba or Norcardia keratitis. PCR is not in widespread use, but has high sensitivity and specificity, and may facilitate early diagnosis and specific treatment of the causative organism, which is critical in obtaining the best clinical outcome.

Ocular infections caused by non-tuberculous mycobacteria: update on epidemiology and management

BACKGROUND

  To provide an update on the frequency, distribution, risk factors and in vitro susceptibility of ocular infections caused by non-tuberculous mycobacteria.

DESIGN

  Retrospective study of university clinic patients.

PARTICIPANTS

  One hundred thirty-nine patients with culture confirmed non-tuberculous mycobacteria infections seen at Bascom Palmer Eye Institute from January 1980 to July 2007.

METHODS

  Chart review of data collected included patients' demographics, risk factors, microbiological profiles and clinical outcomes.

MAIN OUTCOME MEASURES

  Frequency, distribution, risk factors and in vitro susceptibility of ocular infections caused by non-tuberculous mycobacteria.

RESULTS

  A total of 183 non-tuberculous mycobacteria isolates from 142 eyes were identified, with a fourfold increase in the number of eyes infected with non-tuberculous mycobacteria from 1980-1989 (13.4%) to 2000-2007 (56.3%). Eighty-three percent of non-tuberculous mycobacteria isolates were identified as M. abscessus/chelonae. The majority (91%) of isolates were recovered within 10 days. Common diagnoses included keratitis (36.6%), scleral buckle infections (14.8%) and socket/implant infections (14.8%). Identifiable risk factors were presence of biomaterials (63.1%), ocular surgery (24.1%) and steroid exposure (77%). The median time from diagnosis of culture positive non-tuberculous mycobacteria infection to resolution was 13 to 24 weeks. Combination therapy was used to treat 80% of infected eyes. In vitro susceptibility of non-tuberculous mycobacteria isolates were: amikacin, 81%; clarithromycin, 93%; and moxifloxacin, 21%.

CONCLUSIONS

  The incidence of ocular infections caused by non-tuberculous mycobacteria has increased within the last 8 years, with a high number of biomaterial associated infections among this group. Clinical diagnosis and microbiological confirmation of non-tuberculous mycobacteria infections remains challenging. Patient outcomes may be improved by early diagnosis, appropriate therapy and removal of biomaterials.