Aeromonas sobria endophthalmitis

Australian and New Zealand Jolourna1 of Ophthalmology ( 1997) 2 5 , 299-300

Case Report Aeromonas sobria endophthalmitis Lawrence R Lee, MB, BS, FRACO, FRACS, Stephen O'Hagan, MB, BS and Mark Dal Pra, MB, BS, FRACO,

FRACS Department of Ophthalmology, Royal Brisbane Hospital, Herston, Queensland, Australia

ABSTRACT

CASE REPORT

Background: Aeromonos sobrio causes a rare Gram-negative bacterial water-borne infection.It has been found in waters of North Queensland and South-east Asia. Of all Aeromonos species, A. sobrio is the most virulent and invasive and has been reported t o cause soft tissue infection and corneal ulcer.

A 14-year-old Caucasian male sustained a right penetrating

Methods: A 14-year-old Caucasian male from N orth Queensland presented following a penetrating eye injury in which a water bird (cormorant species) had pecked his eye while he was fishing. A fulminant endophthalmitis developed despite treatment with intravenous, intravitreal and topical antibiotics and initial wound repair. Enucleation was performed. Results: Aeromonos sobrio was isolated from the vitreous aspirate. Conclusion: Aeromonas sobrio infection should be suspected in water-contaminated penetrating eye injuries.The prognosis in this case was poor.

eye injury from a water bird (cormorant species), which pecked his eye. This occurred in Doomadgee, a remote town in N o r t h Queensland, while the boy was holding t h e bird, which had become entangled in, his fishing line. Fifteen hours later the boy arrived at Townsville Base Hospital and, o n examination, he had a full-thickness central corneal laceration with traumatic inferior iridectomy and traumatic cataract with vitreous prolapse into t h e anterior chamber. Initial repair with anterior vitrectomy, removal of some soft lens matter and closure of the corneal laceration was performed. Specimens of vitreous obtained from t h e anterior vitrectomy were sent t o microbiology. Treatment with intravenous cephalothin and gentamicin was commenced and t h e patient was transferred t o Brisbane. At 36 h after the original injury, t h e patient arrived at the Royal Brisbane Hospital and examination revealed an

reported to cause soft tissue infection and corneal ulcer. 1-3 In o n e study from Queensland (Australia), A. sobria infection accounted for 25% of all Aeromonas infection, with another two species, A. bydropbila and A. caoiae, accounting for 71 and 4% of all infections, respectively.2 We present a case of A. sobria endophthalmitis which, t o our knowledge, is the first reported case of endophthalmitis due t o this species, although A. bydropbila endophthalmitis

extremely painful red right eye that had a severe anterior chamber reaction with a 2 mm hypopyon and corneal oedema. The visual acuity was perception of light in the right eye and 6/5 in the left eye. Further anterior vitrectomy was performed and intravitreal injections of vancomycin ( 1 m g in 0.1 mL) and gentamicin (0.2 m g in 0.1 mL) were given. Vitreous aspirates were sent t o microbiology. Intravenous vancomycin and gentamicin were commenced along with guttae gentamicin I .5% q t h and cephalothin 5% q 1 h. A further 36 h later, t h e visual acuity was n o perception of light and there was a total right hypopyon, with corneal abscess formation. Further intravitreal injections of vancomycin ( 1 m g in 0.1 mL) and amikacin (0.4 m g in 0.1 mL) were performed. The following d a y A. sobria sensitive t o gentamicin, cephalothin, chloramphenicol and cotrimoxazole were isolated from t h e vitreous aspirates obtained in

has been reported previously.4

Townsville and Brisbane. Therapy was changed t o an intra-

Key words: Aeromonas sobria, endophthalmitis. Aeromonas sobria causes a Gram-negative bacterial waterborne infection.' It has been found in t h e waters of N o r t h Queensland and South-east Asia.2 Of all Aeromonas species,

A. sobria is t h e most virulent and invasive and has been

W Correspondence Dr Lawrence R Lee, Moorfields Eye Hospital, City Road, London, EClV 2PD, UK Ernail

Lee et al.

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Figure 1. Large hypopyon, corneal abscess and wound rupture with progressive Aeromonas sobria endophthalmitis.

venous third generation cephalosporin and oral cotrimoxa-

zole. O n the fifth day following the initial injury, despite treatment, the corneal wound broke down with pus extruding from the eye (Fig. 1). An enucleation was performed. Histology revealed a severe acute inflammatory reaction with disruption of the intraocular contents and cornea.

DISCUSSION This case represents a rapidly progressive fulminant endophthalmitis due to A. robria with poor outcome. The decision to use intravenous antibiotics in this case was made before the Endophthalmitis Vitrectomy Study (EVS)5 results were published. If the patient had undergone intravitreal antibiotic injection at the time of initial repair and had there been less delay in treatment, the outcome may have been different. Aeromonar sobria was still identified in vitreous aspirates taken after the patient had been treated with intravenous antibiotics for 2 t h. This case demonstrates the ineffectiveness of intravenous antibiotics in A. sobria endophthalmitis, the urgency of appropriate treatment and the aggressive nature of this infection. Topical antibiotics are of doubtful significance due to poor penetration in endophthalmitis; however, in this case they proved useful, as there was also a corneal infection and a penetrating wound. The collection of vitreous a n d o r other relevant intraocular specimens is essential whenever there is a penetrating

eye injury, especially in those at high risk, such as in animal, soil- or water-contaminated injuries. Once intravitreal antibiotics are given, the infecting organism may be difficult to obtain by subsequent vitreous aspirate. Although the E V S did not study post-traumatic endophthalmitis, implications for management of this infection are useful. Following collection of intraocular specimens for microbiology and primary repair of the ocular injury, consideration should be given to the intravitreal injection of the antibiotics vancomycin ( 1 mg in 0.1 mL) and amikacin (0.4 mg in 0.1mL) or ceftazidime (2.25 mg in 0.1 mL) and the application of a topical antibiotic, steroid and cycloplegia. The present case presents typical features of A. sobria infection. I t is usually (98%) sensitive to cephalothin and 100% sensitive to gentamicin and third generation cephalosporins.6 Other cases reported in the literature have responded to treatment, although these cases were not penetrating eye injuries.1.3 Ophthalmologists should be aware of A. sobria infection and suspect this in any water-borne ocular injury. T h e outcome in this case was poor.

ACKNOWLEDGEMENT The authors thank Drs Lillicrap and Kelly (Townsville, QLD, Australia) for referring this patient. We also thank the Departments of Microbiology at the Royal Brisbane Hospital and at the Townsville Base Hospital for their assistance.

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sobria. Clin. Inject. Dis. 1993; 17: 1082-3. Feaster Nisbet RM, Barber JC. Aeromonas bydropbila corneal

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ulcer. Am. J. Opbtbalmol. 1978; 8 5 : 114-17. 5. Endophthalmitis Vitrectomy Study Group. Results of the endophthalmitis vitrectomy study. Arcb. Opbtbalmol. 1995; 1 13: 1479-96. 6 . Koehler JM, Ashdown LR. In uitro susceptibilities of tropical strains of Aeromonas species from Queensland, Australia, to 22 antimicrobial agents. Antimicrob. Agents Cbemotber. 1993; 3 7: 905-7.