|Year : 2016 | Volume
| Issue : 3 | Page : 382-384
Post-traumatic endophthalmitis caused by Streptococcus parauberis: First human case report
K Zaman1, A Thakur2, VL Sree1, S Kaushik2, V Gautam1, P Ray1
1 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||20-Oct-2015|
|Date of Acceptance||30-Jun-2016|
|Date of Web Publication||12-Aug-2016|
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
A 12-year-old boy presented with trauma to left eye with a wooden stick. On examination, there was full thickness corneal laceration with cataractous lens behind the laceration. The laceration was sutured, and intravitreal injections of vancomycin, ceftazidime and clindamycin were administered. Vitreous tap grew Streptococcus parauberis. The isolate was sensitive to amoxicillin, erythromycin and vancomycin, and topical vancomycin was used to treat the infection. We present the first case of human post-traumatic infective endophthalmitis caused by the rare agent S. parauberis.
Keywords: Infective endophthalmitis, post-traumatic, Streptococcus parauberis, vancomycin
|How to cite this article:|
Zaman K, Thakur A, Sree V L, Kaushik S, Gautam V, Ray P. Post-traumatic endophthalmitis caused by Streptococcus parauberis: First human case report. Indian J Med Microbiol 2016;34:382-4
|How to cite this URL:|
Zaman K, Thakur A, Sree V L, Kaushik S, Gautam V, Ray P. Post-traumatic endophthalmitis caused by Streptococcus parauberis: First human case report. Indian J Med Microbiol [serial online] 2016 [cited 2020 Jan 29];34:382-4. Available from: http://www.ijmm.org/text.asp?2016/34/3/382/188360
| ~ Introduction|| |
Streptococcus parauberis and Streptococcus uberis are the primary causative agents of bovine mastitis. S. parauberis aquatic infections have been a major concern of economic loss in marine aquaculture system. S. parauberis was first reported from cultured turbot (Scophthalmus maximus) in Spain followed by the increase in frequency of infection of olive flounder (Paralichthys olivaceus) in the aquaculture industries of North-eastern Asia. Till date, in literature, no case of human infection by S. parauberis has been reported. We present the first case of human post-traumatic infective endophthalmitis caused by the rare agent S. parauberis.
| ~ Case Report|| |
A 12-year-old boy complained of eye pain and watering following trauma to the left eye with a wooden stick while playing. He was prescribed some topical eye drops by a local doctor and presented to our centre 6 days after the injury, with no relief of symptoms. On examination of the left eye, the visual acuity was limited to perception of light (PL) with inaccurate projection of rays, and there was a full-thickness corneal laceration involving the pupillary area 6 mm in horizontal diameter sparing the limbus with corneal infiltrates surrounding the lacerated margins. The injury was categorised Type B, Zone I, Grade IV with cataractous lens behind laceration. The corneal laceration was sutured under general anaesthesia, and empirical intravitreal antibiotics, vancomycin 1 mg, ceftazidime 2.25 mg and clindamycin 1 mg were injected. A vitreous tap 0.2 ml was taken through pars plana route and the clear yellow aspirated fluid was sent for microbiological examination.
On the 1 st post-operative day, there was no PL and there were dense corneal infiltrates around the sutured ends. The cataractous lens was bulging behind the sutures, shallowing the anterior chamber [Figure 1]. Ultrasound examination revealed vitreous cavity full of infiltrates suggestive of endophthalmitis. The patient was started on intravenous ciprofloxacin (10 mg/kg body weight 12 hourly) with topical moxifloxacin 0.5%, topical atropine 1%, topical betamethasone 0.1%, along with topical carboxymethylcellulose 0.5%. Vitrectomy was not done due to poor prognosis.
|Figure 1: Post-operative day 1 photograph showing corneal infiltrates around the sutured ends|
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Microscopic examination of vitreous fluid revealed pus cells. The sample was inoculated on 5% sheep blood agar, chocolate agar and MacConkey agar. The culture grew 2-3 mm, smooth, creamy white colonies with alpha haemolysis on blood agar. Gram-stain from the colonies showed Gram-positive cocci in chains. The isolate was subjected to identification by MALDI-TOF MS (Bruker Daltonics, Bremen, Germany). Bruker MALDI Biotyper 3.0 software package was used to analyse the mass spectrum generated and compared with the available reference spectrum database. A score of ≥2 provided species level identification as per the manufacturer's recommendation and available literature. The isolate was identified as S. parauberis with a score of 2.1. The standard Kirby-Bauer disc diffusion method was used for antibiotic susceptibility testing as per CLSI guidelines (CLSI 2015). The isolate was sensitive to amoxicillin, erythromycin and vancomycin, and resistant to co-trimoxazole and clindamycin. Microscopy and culture were negative for fungal pathogens.
Topical vancomycin 5% was added to the above treatment. After 4 days of starting topical vancomycin, there was a decrease in corneal infiltrates [Figure 2]. Visual acuity was still documented as no perception of light. Ultrasonography revealed retinal detachment with vitreous haemorrhage. The patient was discharged, and 'no visual prognosis' was explained and advised for follow-up.
|Figure 2: Photograph at the time of discharge showing reduced corneal infiltrates|
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| ~ Discussion|| |
Paediatric infectious endophthalmitis is a devastating condition. It is mainly caused by open-globe injuries and glaucoma surgery.  Open-globe injury is the most common cause of endophthalmitis in children, with an estimated incidence range of 2-54.2%.  Post-traumatic endophthalmitis is often polymicrobial in nature compared to other forms of exogenous endophthalmitis.
The culture positivity for exogenous infectious endophthalmitis ranges from 44% to 75% and the most common organisms recovered are Gram-positive bacteria,  mostly sensitive to vancomycin. Staphylococcus spp., especially coagulase negative staphylococci, are the most common followed by Streptococcus spp. and Bacillus spp.  Streptococci are more common causes in the paediatric age group, whereas in adults, it is Staphylococcus epidermidis. Among the Streptococcus species, viridans streptococci are the most common, followed by Streptococcus pneumoniae and β-haemolytic streptococci.  Patients with streptococcal endophthalmitis have poorer visual outcomes compared to that of staphylococcal infection.
S. parauberis is a Gram-positive coccus, non-motile, non-sporing and catalase negative. They are facultatively anaerobic and grow at 30-37°C. Of the phylogenetic groups of genus Streptococcus, S. parauberis belongs to the pyogenic group and Lancefield E serogroup. When compared to other pyogenic streptococci, S. uberis and S. parauberis are alpha- or non-haemolytic [Figure 3].  The only phenotypic test to differentiate S. uberis and S. parauberis is the enzyme β-D-glucuronidase activity.  Even the literature reports the difficulty in establishing the identification of these species.  Isolation of a non-haemolytic Streptococcus species especially in mixed culture may be dismissed as an insignificant contaminant. In the present case, identification was established by mass spectrometry-based MALDI-TOF. Various studies have shown that MALDI-TOF MS has better efficacy in identifying the alpha haemolytic streptococci. 
S. parauberis and S. uberis are the primary causative agents of bovine mastitis.  Marine streptococcosis is a major concern of economic loss in marine aquaculture system. S. parauberis was first reported from cultured turbot (S. maximus) in Spain followed by the increase in frequency of infection of olive flounder (P. olivaceus) in the aquaculture industries of North-eastern Asia. Recently, in the USA, natural infection by S. parauberis was reported in wild striped finfish (Morone saxatilis).  Most of the isolates are sensitive to penicillin, ampicillin, oxacillin, amoxicillin/clavulanic acid and cephalosporins. Resistance has been noted to co-trimoxazole (SXT) and ciprofloxacin.  In our study, the isolate was resistant to co-trimoxazole (SXT), ciprofloxacin and clindamycin and was sensitive to vancomycin. The patient was initially treated with ciprofloxacin with no clinical improvement, and later on the basis of the susceptibility report topical vancomycin was used to treat the infection. Till date, in literature, no case of human infection by S. parauberis has been reported. We present the first case of human post-traumatic infective endophthalmitis caused by the rare agent S. parauberis. Knowledge of the causal rather than casual association of newer species will broaden the list of possible aetiological agents, and their susceptibility profile will help in forming antibiotic treatment policy to target the bacteria empirically as well as definitively.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]