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LETTER TO EDITOR
Year : 2007  |  Volume : 55  |  Issue : 2  |  Page : 160-161

Stromal abscess caused by Enterococcus fecalis : An unusual presentation


Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

Correspondence Address:
G Arvind
Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.30723

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How to cite this article:
Subashini K, Arvind G, Sabyasachi S, Renuka S. Stromal abscess caused by Enterococcus fecalis : An unusual presentation. Indian J Ophthalmol 2007;55:160-1

How to cite this URL:
Subashini K, Arvind G, Sabyasachi S, Renuka S. Stromal abscess caused by Enterococcus fecalis : An unusual presentation. Indian J Ophthalmol [serial online] 2007 [cited 2019 Aug 23];55:160-1. Available from: http://www.ijo.in/text.asp?2007/55/2/160/30723

Dear Editor,

Enterococcus fecalis is a gram-positive organism, which can cause systemic infections like endocarditis, intra-abdominal sepsis including bacteremia.[1] In the eye, E . fecalis is a well-known cause of endophthalmitis.[2] Primary corneal involvement by this organism has seldom been reported. We describe a case of corneal stromal abscess caused by E. fecalis , which resolved with medical treatment.

A 30-year-old lady with injury to the right eye (RE) with her own fingernail presented with pain and diminution of vision of five days duration. She had no systemic illness. RE examination revealed vision of finger counting, lid edema and circumcorneal congestion. A supero-nasal corneal stromal abscess of 32 mm with intact overlying epithelium was seen associated with stromal edema, hypopyon (3 mm), and fibrinous uveitis [Figure - 1]a. The intraocular pressure was normal. Vitreous was anechoic on ultrasonography B scan. The left eye (LE) was normal with vision of 20/20. Corneal scraping was performed after removing the corneal epithelium over the abscess area and material was sent for Gram's stain (GS), KOH, Acanthamoeba wet mount, bacterial, and fungal culture. She was started empirically on 1-hourly-0.3%-ofloxacin. Gram's stain revealed gram-positive diplococci but KOH and wet mount were negative. Bacterial culture grew E. fecalis colonies sensitive to ampicillin, amoxycillin, penicillin, and vancomycin but resistant to tobramycin, gentamycin, ciprofloxacin and ofloxacin. Bacterial cultures from right conjunctival sac and nail-bed of both hands were obtained but only the culture from the nail-bed of right hand grew the same organism.

The topical medication was changed to 1-hourly-vancomycin (50 mg/mL). There was gradual disappearance of the hypopyon but a posterior stromal abscess rapidly evolved in the inferior cornea [Figure - 1]b. This continued to increase until it formed kissing stromal abscess along with the superior abscess [Figure - 1]c. With the continuation of the same medication both the abscesses started reducing in size and finally a vascularized macular scar was left superonasally [Figure - 1]d by the end of three weeks. The best-corrected visual acuity in RE was 20/40.

E. fecalis is an opportunistic pathogen known to cause urinary tract infection in catheterized patients and intra-abdominal infection like gastroenteritis. The infection is more severe in diseases where phagocytosis by leucocytes is reduced as in diabetes mellitus. Lee et al. reported a case of postoperative endophthalmitis, who subsequently developed corneal ulcer[3] but our patient was healthy with no pre-disposing condition. It has also been reported as a cause of crystalline keratopathy following penetrating keratoplasty (PK), which did not respond to treatment and eventually required repeat PK.[4]

E. fecalis has a remarkable capacity to acquire resistance to antimicrobial agents, which is either due to production of enzymes that inactivate these agents or from changes in the molecular targets.[4],[5] E. fecalis' endophthalmitis is fulminant and is usually associated with poor visual outcome.[2] Resistance to tetracycline, erythromycin, chloramphenicol, gentamicin, aminoglycosides, and cephalosporins are very common.[4],[5]

Corneal infection in this case was by exogenous inoculation into the eye as the patient had injury with nail and the nail bed grew the same pathogen. In vitro susceptibility testing may not correlate with the in vivo response to antibiotics which is commonly seen with E. fecalis ,[5] but in our case the organism responded adequately in accordance to the in vitro susceptibility. The ethyl-cyanoacrylate has been shown to have bacteriostatic effect on E. fecalis but the bactericidal effect is only 40%.[6]

However, with the evolution of inferior corneal abscess it appeared as if the organism was not responding to vancomycin adequately. Continuation of the same medication led to resolution of the disease. Corneal stromal abscess may take time to respond and the medication might have to be continued long before adequate response is seen.

 
  References Top

1.
Chenoweth C, Schaberg D. The epidemiology of enterococci. Eur J Clin Microbiol Infect Dis 1990;9:80-9.  Back to cited text no. 1
[PUBMED]    
2.
Scott IU, Loo RH, Flynn HW Jr, Miller D. Endophthalmitis caused by Enterococcus fecalis : Antibiotic selection and treatment outcomes. Ophthalmology 2003;110:1573-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Moellering RC. Enterococcus species, Streptococcus bovis and Leuconostoc species. In : Mandell GL, Bennet JE, Dolin R (editors). Priciples and Practice of Infectious Diseases, 4th ed. Churchill Livingstone: New York; 1995. p. 1826-35.  Back to cited text no. 3
    
4.
Lee SM, Lee JH. A case of Enterococcus fecalis endophthalmitis with corneal ulcer. Korean J Ophthalmol 2004;18:175-9.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.
Lam S, Meisler DM, Krachmer JH. Enterococcal infectious crystalline keratopathy. Cornea 1993;12:273-6.  Back to cited text no. 5
[PUBMED]    
6.
de Almeida Manzano RP, Naufal SC, Hida RY, Guarnieri LO, Nishiwaki-Dantas MC. Antibacterial analysis in vitro of ethyl-cyanoacrylate against ocular pathogens. Cornea 2006;25:350-1.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  


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