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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 32  |  Issue : 3  |  Page : 331-332
 

Polymicrobial chronic endophthalmitis diagnosed by culture and molecular technique


1 Consultant Microbiologist, Sankara Nethralaya, Kolkata, West Bengal, India
2 Microbiologist, Sankara Nethralaya, Kolkata, West Bengal, India
3 Department of Microbiology, Sankara Nethralaya, Kolkata, West Bengal, India
4 Vitro-retina services, Consultant, Vitro-retina services, Sankara Nethralaya, Kolkata, West Bengal, India
5 Head of the Department, L&T Microbiology Research Centre, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission12-Sep-2013
Date of Acceptance10-Oct-2013
Date of Web Publication10-Jul-2014

Correspondence Address:
A Mukherjee
Consultant Microbiologist, Sankara Nethralaya, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.136593

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 ~ Abstract 

Accurate etiological diagnosis is the key to prevention of ocular morbidity in endophthalmitis cases. A 66 year old male was suffering from chronic endophthalmitis post-cataract surgery. Polymerase chain reaction examination on anterior chamber fluid was positive for Propionibacterium acnes but negative for the panfungal genome. He was advised vitrectomy with intravitreal injections. Polymerase chain reaction of vitreous aspirate was positive for P.acnes as well as panfungal genome. The vitreous sample also grew yeast in culture which was identified as Candida pseudotropicalis. Patient was treated on an alternate day regimen of intravitreal Vancomycin and Amphotericin B in the post-operative period. There was improvement in vision at final follow up. Chronic endophthalmitis can have polymicrobial etiology which will require appropriate diagnostic and therapeutic strategies. The role of molecular testing is vital in these cases as growth in culture is often negative.


Keywords: Endophthalmitis, polymerase chain reaction, propionibacerium acnes


How to cite this article:
Mukherjee A, Pramanik S, Das D, Roy R, Therese K L. Polymicrobial chronic endophthalmitis diagnosed by culture and molecular technique. Indian J Med Microbiol 2014;32:331-2

How to cite this URL:
Mukherjee A, Pramanik S, Das D, Roy R, Therese K L. Polymicrobial chronic endophthalmitis diagnosed by culture and molecular technique. Indian J Med Microbiol [serial online] 2014 [cited 2019 Sep 17];32:331-2. Available from: http://www.ijmm.org/text.asp?2014/32/3/331/136593



 ~ Introduction Top


Endophthalmitis refers to intraocular inflammation predominantly involving the anterior chamber and the vitreous cavity of the eye. It is one of the most devastating ocular complications that can occur following surgery. [1] Accurate and early etiological diagnosis is the key to initiation of appropriate treatment to prevent long-term ocular morbidity. However, conventional microbiological techniques are known to have very low sensitivity due to low volume of intraocular fluid sample available for analysis as well as the low number of organisms required to initiate a fulminant endophthalmitis. In this situation, molecular techniques like polymerase chain reaction (PCR) are of great help. We discuss here a case of endophthalmitis caused by multiple aetiological agents, who could only be diagnosed by the use of molecular diagnostic methods like PCR as conventional microbiological techniques like smear and culture of intraocular fluids (aqueous and vitreous humour) failed to yield positive results. In the present case, accurate diagnosis and treatment helped in limiting the ocular morbidity of the patient.


 ~ Case Report Top


PKD, a 66-year-old diabetic and hypertensive male came to our tertiary care speciality ophthalmology hospital with complaints of redness, watering and diminution of vision in the right eye since past 4 months. He had cataract surgery in right eye about a year prior to onset of symptoms. At the time of presentation, he was being treated elsewhere for chronic uveitis.

His best corrected visual acuity was counting fingers at 0.5 m in right eye and 6/9; N6 in the left eye. On examination, anterior segment of the right eye showed conjunctival circumcorneal congestion with anterior chamber reaction. There were retro intraocular lens fluffy white deposits along with severe vitritis. The retina was attached with visibility of only first order vessels. Disc was seen hazily. Left eye was within normal limits.

He was advised microbiological evaluation of anterior chamber fluid. PCR examination on anterior chamber fluid was positive for Propionibacterium acnes but negative for the panfungal genome [Figure 1] left panel]. However, no bacteria (aerobic and anaerobic) or fungi grew in culture even after 12 days of incubation. A diagnosis of chronic endophthalmitis was made and he was advised urgent surgical intervention.

He subsequently underwent vitrectomy with intraocular lens removal with administration of intravitreal antibiotics (Vancomycin + Ceftazidime) along with Decadron.

PCR of vitreous aspirate was positive for P. acnes as well as panfungal genome [Figure 1] right panel]. The vitreous sample also grew white, creamy, pasty colonies after 48 h of incubation. The colonies showed budding yeast cells on Gram stain, which were germ tube negative. The organism was morphologically identified as Candida pseudotropicalis based on the presence of abundant hyphal elements in the characteristic 'logs in a stream' fashion and rare presence of blastospores on corn meal agar. Based on the microbiological reports, patient was treated on an alternate day regimen of intravitreal Vancomycin and Amphotericin B in the post-operative period. At final follow up his vision improved to 6/24, media was clear and retina was attached.
Figure 1: Gel picture showing PCR from aquous humor positive for P.acnes (left) and in vitreous humor for fungus (right) which was also positive for P. acnes NC-negative control, PC-positive control 100 bp molecular markers have been used. Amplicon size has been indicated in the picture

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 ~ Discussion Top


Polymicrobial eye infections present a challenge not only in terms of identification of the causative organism, but also in instituting appropriate antimicrobial therapy. Large studies have reported variable prevalence of polymicrobial infection (3.88-20.4% of culture proven endophthalmitis) from different parts of the world including India. [2],[3],[4],[5]

However, the actual number is likely to be higher as all these studies have recruited only culture proven cases. Besides, they have looked at only cases of acute-onset endophthalmitis. In case of our patient, the endophthalmitis started almost one year after the cataract surgery. P. acnes and Candida are both known to cause chronic endophthalmitis. [6] While we did perform anaerobic culture for isolation of P. acnes, we did not get any growth while PCR done on the aqueous tap was positive. This is explained by the fact that although P. acnes is aerotolerant, but still it requires stringent growth conditions. [7] Prior antibiotic therapy may also be the reason. In this scenario, the role of molecular diagnosis is invaluable. In the present case, PCR helped in detection of the two different pathogens (the fungus also grew in culture thereby confirming the findings of the PCR). Based on the results, appropriate management was initiated in the patient that helped him in partially regaining his vision.

The present case highlights the fact that chronic endophthalmitis can have polymicrobial aetiology, which will require appropriate diagnostic and therapeutic strategies. The role of molecular testing is vital in these cases as growth in culture is often negative. It has also been seen that vitreous aspirate is a more representative sample in comparison to aqueous aspirate. It can thus be recommended that wherever possible, vitreous aspirate should be investigated for possible microbial aetiology of endophthalmitis.

 
 ~ References Top

1.Scott IU, Flynn HW Jr, Feuer W, Pflugfelder SC, Alfonso EC, Forster RK, et al. Endophthalmitis associated with microbial keratitis. Ophthalmology 1996;103:1864-70.  Back to cited text no. 1
    
2.Pijl BJ, Theelen T, Tilanus MA, Rentenaar R, Crama N. Acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the Netherlands. Am J Ophthalmol 2010;149:482-7.  Back to cited text no. 2
    
3.Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, et al. Spectrum and clinical profile of post cataract surgery endophthalmitis in North India. Indian J Ophthalmol 2003;51:139-45.  Back to cited text no. 3
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4.Jindal A, Moreker MR, Pathengay A, Khera M, Jalali S, Majji A, et al. Polymicrobial endophthalmitis: Prevalence, causative organisms, and visual outcomes. J Opthalmic Inflamm Infect 2013;3:6.  Back to cited text no. 4
    
5.Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative. endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000;48:123-8.  Back to cited text no. 5
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6.6. Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D, Meisler DM. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. 6. Ophthalmology 1999;106:1665-70.  Back to cited text no. 6
    
7.Aldave AJ, Stein JD, Deramo VA, Shah GK, Fischer DH, Maguire JI. Treatment strategies for postoperative Propionibacterium acnes endophthalmitis. Ophthalmology 1999;106:2395-401.  Back to cited text no. 7
    


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