[Morganella morganii endophthalmitis after vitrectomy: case report and review of the literature]

Morganella morganii and Enterococcus faecalis endophthalmitis following intravitreal injection

BACKGROUND

Endophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported.

CASE PRESENTATION

We present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence.

CONCLUSIONS

Post-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis.

A Rare Case of Fulminant Acute Postoperative Morganella morganii Endophthalmitis

PURPOSE

The authors present a case of a 60-year-old Indian female presented with sudden loss of vision in the right eye three days after an uneventful cataract surgery which revealed a rare organism and which was treated successfully.

METHODS

She was diagnosed with acute postoperative endophthalmitis with fulminant disease and on further work up, culture showed Morganella morganii (gram negative bacilli).

RESULTS

She was successfully treated with intravitreal imipenem, dexamethasone and vitrectomy. A review of literature was conducted to identify and discuss additional reports on similar cases. As per PubMed search with keywords "Morganella morganii endophthalmitis" this is the best achieved visual outcome to date in a case of acute post-operative Morganella morganii endophthalmitis.

CONCLUSION

Intravitreal imipenem can be considered to treat Morganella morganii endophthalmitis. Aggressive treatment in these patients can help in improving visual outcome.

Postvitrectomy endophthalmitis caused by Morganella morganii: a case report and literature review

Background

Postvitrectomy endophthalmitis is a rare and serious complication following vitreoretinal surgeries. Morganella morganii, an emerging gram-negative, facultative anaerobic rod, is related to severe nosocomial infections in various organs and thus has gained importance in recent decades. Morganella morganii infection following intraocular surgery is rarely reported.

Case presentation

We report an immunocompetent patient with Morganella morganii-related endophthalmitis after vitrectomy for retinal detachment who presented with hand motion visual acuity, hypopyon and a unique retrolental exudative membrane. Initially, the patient was unresponsive to empirical intravitreal ceftazidime and vancomycin but recovered with vision preservation (20/63) after surgical removal of the membrane and silicone oil tamponade.

Conclusions

Morganella morganii intraocular infection is often devastating, likely due to its high multidrug-resistance rate via intrinsic ß-lactamase production, multiple acquired traits related to additional genetic mechanisms, and fimbrial adhesion, urease production, and type III secretion system-associated biofilm formation. The above characteristics of M. morganii may lead to an inadequate response to empirical intravitreal antibiotics, and early surgical intervention should be considered.

Morganella morganii, a non-negligent opportunistic pathogen

Morganella morganii belongs to the tribe Proteeae of the Enterobacteriaceae family. This species is considered as an unusual opportunistic pathogen that mainly causes post-operative wound and urinary tract infections. However, certain clinical M. morganii isolates present resistance to multiple antibiotics by carrying various resistant genes (such as blaNDM-1, and qnrD1), thereby posing a serious challenge for clinical infection control. Moreover, virulence evolution makes M. morganii an important pathogen. Accumulated data have demonstrated that M. morganii can cause various infections, such as sepsis, abscess, purple urine bag syndrome, chorioamnionitis, and cellulitis. This bacterium often results in a high mortality rate in patients with some infections. M. morganii is considered as a non-negligent opportunistic pathogen because of the increased levels of resistance and virulence. In this review, we summarized the epidemiology of M. morganii, particularly on its resistance profile and resistant genes, as well as the disease spectrum and risk factors for its infection.

Conjunctival flora of clinically normal and diseased turtles and tortoises

BACKGROUND

In captive breed turtles and tortoises conjunctival disease is common. Our aim was to investigate the bacterial and fungal flora present in the eyes of healthy and pathological chelonians and to compare findings in turtles with those in tortoises.

RESULTS

Samples were taken from the conjunctival sacs of 34, diseased and healthy, chelonians (18 tortoises and 16 turtles) and submitted to bacterial and fungal investigation. All samples showed bacterial growth. Thirteen animals (38%), harboured a single bacterial species as sole isolate and twenty-one animals (62%) harboured more than one species. Detection of multiple bacterial infection was clearly greater in tortoises compared to turtles. Most frequently isolated bacterial species were Bacillus spp. (13 isolates), Staphylococcus xylosus (10 isolates), Sphingomonas paucimobilis (6 isolates), Staphylococcus sciuri and Aeromonas hydrophila/caviae (each 5 isolates), Ochrobactrum anthropi (3 isolates), Citrobacter freundii, Enterobacter cloacae and Pseudomonas luteola (each 2 isolates). Only one isolate of Kocuria varians/rosea, Staphylococcus aureus, Staphylococcus auricularis, Staphylococcus haemolyticus, Staphylococcus lentus, Morganella morganii, Pasteurella multocida, Pasteurella pneumotropica/haemolytica, Proteus spp., Pseudomonas putida, Salmonella enterica ssp. arizonae, Stenotrophomonas maltophilia and Vibrio parahaemolyticus was evidenced. The presence in 8 animals of Mycoplasma spp. and in 1 animal with severe conjunctivitis of Chlamydia spp. was detected by PCR. Candida spp. was also isolated from two healthy animals.

CONCLUSIONS

A clear predominance of Gram positive isolates in tortoises and Gram negative isolates in turtles was found. However, we cannot ascribe the observed difference to the diversity of animal species, as other factors, including especially different characteristics of the living environments, may play a role. Almost all bacterial species isolated may have clinical significance, mostly as opportunistic pathogens, both for humans and animals. That chelonians are often carrier of bacteria with zoonotic potential is a well-known fact, in particular with regard to Salmonella spp. Therefore, it is not surprising the detection of a strain of Salmonella enterica ssp. arizonae in the eye of one of the animals tested. Worthy of note is the finding of Chlamydia spp. in a severe case of conjunctivitis, though we cannot epidemiologically assess a cause-effect relationship between presence of chlamydia and disease.