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Liu J, Guo X, Wei Z, Zhang Y, Zhang Z, Xu X, Liang Q. Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature. Eye Contact Lens 2023; 49:275-282. [PMID: 37166228 PMCID: PMC10281179 DOI: 10.1097/icl.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery. METHODS To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article. RESULTS Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%). CONCLUSIONS Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.
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Affiliation(s)
- Jiamin Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xiaoyan Guo
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zhenyu Wei
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Yuheng Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zijun Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xizhan Xu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Qingfeng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Ong HS, Sharma N, Phee LM, Mehta JS. Atypical microbial keratitis. Ocul Surf 2023; 28:424-439. [PMID: 34768003 DOI: 10.1016/j.jtos.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/16/2023]
Abstract
Atypical microbial keratitis refers to corneal infections caused by micro-organisms not commonly encountered in clinical practice. Unlike infections caused by common bacteria, cases of atypical microbial keratitis are often associated with worse clinical outcomes and visual prognosis. This is due to the challenges in the identification of causative organisms with standard diagnostic techniques, resulting in delays in the initiation of appropriate therapies. Furthermore, due to the comparatively lower incidence of atypical microbial keratitis, there is limited literature on effective management strategies for some of these difficult to manage corneal infections. This review highlights the current management and available evidence of atypical microbial keratitis, focusing on atypical mycobacteria keratitis, nocardia keratitis, achromobacter keratitis, and pythium keratitis. It will also describe the management of two uncommonly encountered conditions, infectious crystalline keratopathy and post-refractive infectious keratitis. This review can be used as a guide for clinicians managing patients with such challenging corneal infections.
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Affiliation(s)
- Hon Shing Ong
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore; Tissue Engineering and Cell Therapy Department, Singapore Eye Research Institute, Singapore; Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore.
| | - Namrata Sharma
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Lynette M Phee
- Department of Pathology, Sengkang General Hospital, SingHealth, Singapore
| | - Jodhbir S Mehta
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore; Tissue Engineering and Cell Therapy Department, Singapore Eye Research Institute, Singapore; Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore; School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore.
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Ko J, Kim SK, Yong DE, Kim TI, Kim EK. Delayed onset Mycobacterium intracellulare keratitis after laser in situ keratomileusis: A case report and literature review. Medicine (Baltimore) 2017; 96:e9356. [PMID: 29390522 PMCID: PMC5758224 DOI: 10.1097/md.0000000000009356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Infectious keratitis is a relatively uncommon but potentially sight-threatening complication of laser in situ keratomileusis (LASIK). Mycobacterial keratitis is usually regarded as late onset keratitis among post-LASIK keratitis. There has been no documented case of Mycobacterium intracellulare post-LASIK keratitis of a long-latent period. PATIENT CONCERNS A 36-year-old man was referred to our out-patient clinic, for persistent corneal epithelial defect with intrastromal infiltration. He had undergone uneventful bilateral LASIK procedure 4 years before. He complained decreased vision, accompanied by ocular pain, photophobia, and redness in his left eye for 7 months. DIAGNOSIS Lamellar keratectomy was taken using femtosecond laser. Bacterial culture with sequenced bacterial 16s ribosomal DNA confirmed the organism to be M intracellulare. INTERVENTIONS After 3 months of administration of topical clarithromycin, amikacin, and moxifloxacin, the corneal epithelial defect was resolved and the infiltration was much improved. However, newly developed diffuse haziness with surrounding granular infiltration in the central cornea was noted. Drug toxicity was suspected and topical moxifloxacin was discontinued, resulting in resolution of the diffuse haze with infiltration. OUTCOME The patient was followed up regularly without medication thereafter and recurrence was not found for 7 years. LESSONS This case presents the first case of M intracellulare keratitis after LASIK. LASIK surgeons should aware that post-LASIK keratitis can develop long after the operation and careful suspicion of infectious disease with meticulous diagnostic test is needed.
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Affiliation(s)
- JaeSang Ko
- Department of Ophthalmology, Corneal Dystrophy Research Institute, Institute of Vision Research, Yonsei University College of Medicine
| | | | - Dong Eun Yong
- Research Institute of Bacterial Resistance, Department of Laboratory Medicine, Yonsei University College of Medicine
| | - Tae-im Kim
- Department of Ophthalmology, Corneal Dystrophy Research Institute, Institute of Vision Research, Yonsei University College of Medicine
| | - Eung Kweon Kim
- Department of Ophthalmology, Corneal Dystrophy Research Institute, Institute of Vision Research, Yonsei University College of Medicine
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
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MYCOBACTERIUM MANITOBENSE MASQUERADING AS CORYNEBACTERIUM PSEUDODIPHTHERITICUM IN A CASE OF POSTCATARACT SURGERY ENDOPHTHALMITIS. Retin Cases Brief Rep 2015; 10:316-9. [PMID: 26674275 DOI: 10.1097/icb.0000000000000266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a case of postoperative Mycobacterium manitobense endophthalmitis with good visual outcome that is the first report of endophthalmitis by this organism. METHODS Clinical and microbiological description of a patient with postoperative endophthalmitis. RESULTS A 50-year-old chronic alcoholic man was referred to us with decreased vision in his right eye for 4 days. He had undergone cataract surgery with intraocular lens implantation in his right eye a month ago. The presenting vision in his right eye was counting fingers close to face. He was diagnosed as a case of postoperative endophthalmitis. Subsequently, the patient underwent pars plana vitrectomy and vitreous biopsy. The microbiologic investigation of the vitreous biopsy showed poorly stained gram-positive beaded bacilli that were acid fast, and growth in culture was identified as Corynebacterium pseudodiphtheriticum by Vitek 2 bacterial identification system. However, DNA analysis confirmed the organism to be M. manitobense. The patient responded well to repeat interventions with intravitreal antibiotics with a final reported visual acuity of 20/30 at 4 months after first intervention. CONCLUSION Although known to be an organism causing soft-tissue infections, M. manitobense can also cause postsurgical endophthalmitis. The diagnosis can be confused with Corynebacterium sp. on smear and culture. Subsequent DNA sequencing of the culture provides definite identification of the organism.
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Post-keratorefractive Surgery Infections: Management Strategies. CURRENT OPHTHALMOLOGY REPORTS 2015. [DOI: 10.1007/s40135-015-0074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2015; 2015:164989. [PMID: 26106601 PMCID: PMC4461732 DOI: 10.1155/2015/164989] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 11/01/2022]
Abstract
Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.
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Ide T, Kurosaka D, Senoo T, Kinoshita S, Ohashi Y, Inoue Y, Tsubota K. First multicenter survey on infectious keratitis following excimer laser surgery in Japan. Taiwan J Ophthalmol 2014. [DOI: 10.1016/j.tjo.2014.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Zhang J, Wang L, Zhou J, Zhang L, Xia H, Zhou T, Zhang H. Ocular penetration and pharmacokinetics of topical clarithromycin eye drops to rabbits. J Ocul Pharmacol Ther 2013; 30:42-8. [PMID: 24199739 DOI: 10.1089/jop.2013.0042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To evaluate the ocular pharmacokinetics of clarithromycin (CLA) eye drops topically applied to the corneas of rabbits. METHODS One 50-μL drop of CLA (0.25%) was administered to each New Zealand white rabbit in a single dose group, and one 50-μL drop of CLA was administered 6 times at 5-min intervals to each rabbit in a loading dose group. The effect of debridement on corneal penetration was also investigated in a de-epithelium group. The drug concentrations in the cornea and aqueous humor (AH) were assayed using high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS) analysis. RESULTS Maximum CLA levels were achieved in the corneas and AH at 15 and 60 min, respectively, in the intact epithelium eyes in the single dose group (24.54±10.64 μg/g and 0.78±0.22 μg/mL, respectively, mean±the standard error of the mean, n=8). In the loading dose group, 30 min after the last application, the CLA level in the corneas reached 92.26±17.62 μg/g. In the loading dose group, the drug levels in the corneas and AH were significantly increased compared with the drug levels in the corneas with the intact epithelium and de-epithelium eyes in the single dose group at the corresponding time points (P<0.05). The estimated CLA half-lives in the corneas and AH for the intact eyes were 103.28 and 132.61 min, respectively. CONCLUSION Therapeutic CLA levels can be achieved in rabbit corneas after topically applying the drug with eye drops.
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Affiliation(s)
- Junjie Zhang
- 1 Henan Eye Institute, Henan Eye Hospital, Henan Provincial People's Hospital and People's Hospital of Zhengzhou University , Zhengzhou, People's Republic of China
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Moorthy RS, Valluri S, Rao NA. Nontuberculous mycobacterial ocular and adnexal infections. Surv Ophthalmol 2012; 57:202-35. [PMID: 22516536 DOI: 10.1016/j.survophthal.2011.10.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 10/01/2011] [Accepted: 10/04/2011] [Indexed: 10/28/2022]
Abstract
The nontuberculous (also called "atypical") mycobacteria have become increasingly important causes of systemic as well as ocular morbidity in recent decades. All ocular tissues can become infected with these organisms, particularly in patients who are predisposed following ocular trauma, surgery, use of corticosteroids, or are immunocompromised. Because of their relative resistance to available antibiotics, multidrug parenteral therapy continues to be the mainstay of treatment of more serious ocular and adnexal infections caused by nontuberculous mycobacteria (NTM). Periocular cutaneous, adnexal, and orbital NTM infections remain rare and require surgical debridement and long-term parenteral antibiotic therapy. NTM scleritis may occur after trauma or scleral buckling and can cause chronic disease that responds only to appropriate antibiotic therapy and, in some cases, surgical debridement and explant removal. NTM infectious keratitis following trauma or refractive surgical procedures is commonly confused with other infections such as Herpes simplex keratitis and requires aggressive topical therapy and possible surgical debridement, particularly in those cases occuring after laser in situ keratomileusis. Only 18 cases of endophthalmitis due to NTM have been reported. Systemic and intraocular antibiotic therapy and multiple vitrectomies may be needed in NTM endophthalmitis; the prognosis remains poor, however. Disseminated NTM choroiditis in acquired immune deficiency syndrome patients with immune reconstitution during highly active anti-retroviral therapy is a rare infection that can present as a necrotizing chorioretinitis with dense vitritis, mimicking many other entities and needs to be recognized so that timely, life-saving treatment can be administered. Regardless of which ocular tissue is infected, all NTM ocular infections present similar challenges of recognition and of therapeutic intervention. We clarify diagnosis and delineate modern, effective therapy for these conditions.
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Affiliation(s)
- Ramana S Moorthy
- Indiana University Medical Center, Department of Ophthalmology, Vincent Hospital, Indianapolis, IN 46260, USA.
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Solomon R, Donnenfeld ED, Holland EJ, Yoo SH, Daya S, Güell JL, Mah FS, Scoper SV, Kim T. Microbial keratitis trends following refractive surgery: results of the ASCRS infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg 2011; 37:1343-50. [PMID: 21700112 DOI: 10.1016/j.jcrs.2011.05.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/03/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022]
Abstract
In 2008, the American Society of Cataract and Refractive Surgery (ASCRS) surveyed its 9121 United States and international members to evaluate the changing trends and incidence, culture results, treatment, and visual outcomes of infectious keratitis following keratorefractive procedures worldwide. This paper presents and analyzes the results with comparisons to the data in surveys conducted in 2001 and 2004. Nineteen infections were reported by 14 surgeons who had performed an estimated 20,941 keratorefractive procedures, an incidence of 1 infection in every 1102 procedures. Sixteen cases presented in the first postoperative week, 1 case during the second week, 1 case between the second and fourth weeks, and 1 case at 1 month or later. The 16 cases that presented in the first week were diagnosed at initial presentation. The most common organism cultured was methicillin-resistant Staphylococcus aureus (MRSA). Microbial keratitis following refractive surgery is an increasingly recognized sight-threatening complication.
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Affiliation(s)
- Renée Solomon
- Department of Ophthalmology, NYU Medical Center, New York, New York, USA.
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Abstract
PURPOSE OF REVIEW To review new clinically relevant data regarding the prevention cause and treatment of laser in-situ keratomileusis (LASIK) infections. RECENT FINDINGS Many recent studies of post-LASIK infectious keratitis show the predominance of atypical mycobacteria and Gram-positive cocci and the growing number of other rare pathogens. The American Society of Cataract and Refractive Surgery White Paper treatment paradigm remains the model for initial treatment of LASIK-associated infectious keratitis. SUMMARY Improved understanding of the risk factor, different causes, along with a high degree of suspicion on initial presentation is crucial in order to provide the appropriate management in LASIK-associated infectious keratitis.
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Yamaguchi T, Bissen-Miyajima H, Hori-Komai Y, Matsumoto Y, Ebihara N, Takahashi H, Tsubota K, Shimazaki J. Infectious keratitis outbreak after laser in situ keratomileusis at a single laser center in Japan. J Cataract Refract Surg 2011; 37:894-900. [DOI: 10.1016/j.jcrs.2010.11.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 11/11/2011] [Accepted: 11/11/2011] [Indexed: 10/18/2022]
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Biber JM, Kim JY. Nontuberculous Mycobacteria Keratitis. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Llovet F, de Rojas V, Interlandi E, Martín C, Cobo-Soriano R, Ortega-Usobiaga J, Baviera J. Infectious keratitis in 204 586 LASIK procedures. Ophthalmology 2009; 117:232-8.e1-4. [PMID: 20006909 DOI: 10.1016/j.ophtha.2009.07.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 06/30/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To investigate the incidence, culture results, risk factors, and visual outcomes of infectious keratitis after LASIK, and examine treatment strategies. DESIGN Retrospective study. PARTICIPANTS We included 107 613 patients who underwent LASIK at Clínica Baviera (Instituto Oftalmológico Europeo, Spain) from September 2002 to May 2008. METHODS The medical records of post-LASIK patients (204 586 eyes) were reviewed to identify cases of infectious keratitis. Incidence, risk factors, clinical course, days to diagnosis, medical and surgical treatment, and final visual outcomes were recorded. MAIN OUTCOME MEASURES Incidence of post-LASIK infectious keratitis, culture results, response to treatment, and visual outcome. RESULTS Post-LASIK infectious keratitis was diagnosed in 72 eyes from 63 patients. Onset of infection was early (within 7 days after surgery) in 62.5% of cases. Cultures were positive in 21 of 54 cases in which samples were taken. The most frequently isolated microorganism was Staphylococcus epidermidis (9 cases). Immediate flap lifting and irrigation with antibiotics was performed in 54 eyes; late flap lifting was subsequently required in 10 out of 18 cases initially treated with topical antibiotics alone. One case required flap amputation owing to flap necrosis. Final best spectacle-corrected visual acuity (BSCVA) was >or=20/20 in 38 cases (52.7%) and >or=20/40 in 67 cases (93.05%); final BSCVA was <20/40 in 5 cases (6.94%). CONCLUSIONS The incidence of post-LASIK infectious keratitis was 0.035% per procedure. Infectious keratitis after LASIK is a potentially vision-threatening complication. The appearance of infections in asymptomatic patients highlights the need for a proper schedule of follow-up appointments. Prompt and aggressive management of this LASIK complication with early flap lifting, scraping, culture, and irrigation with antibiotics is strongly recommended. Proper management can result in preserving useful vision. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.
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In Vitro Transcorneal Diffusion of the Antimicrobial Macrolides Azithromycin and Clarithromycin and the Impact on Microbial Keratitis. Cornea 2009; 28:441-6. [DOI: 10.1097/ico.0b013e31818c901f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Meyer JJ, Gelman SS. Multifocal osteomyelitis due to Mycobacterium szulgai in a patient with chronic lymphocytic leukemia. J Infect 2008; 56:151-4. [PMID: 18199481 DOI: 10.1016/j.jinf.2007.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 08/10/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
Abstract
Mycobacterium szulgai is a pathogenic organism that most frequently causes pulmonary infection and may rarely result in disseminated disease in immunocompromised individuals. We report a case of multifocal osteomyelitis and cutaneous lesions due to M. szulgai in a patient with chronic lymphocytic leukemia. The successful treatment of multifocal osteomyelitis was accomplished using isoniazid, rifampin, and ethambutol.
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Affiliation(s)
- Jay J Meyer
- University of Utah School of Medicine, 30 North 1900 East, 4B319, Salt Lake City, Utah 84132, USA
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Sanghvi C. MYCOBACTERIUM FORTUITUM KERATITIS. Indian J Med Microbiol 2007. [DOI: 10.1016/s0255-0857(21)02068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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de la Cruz J, Behlau I, Pineda R. Atypical mycobacteria keratitis after laser in situ keratomileusis unresponsive to fourth-generation fluoroquinolone therapy. J Cataract Refract Surg 2007; 33:1318-21. [PMID: 17586393 DOI: 10.1016/j.jcrs.2007.03.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 03/08/2007] [Indexed: 11/19/2022]
Abstract
We report a case of post-laser in situ keratomileusis atypical mycobacteria infection unresponsive and resistant to fourth-generation fluoroquinolones, which highlights the importance of a high level of suspicion and the need for multidrug therapy for effective eradication.
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Affiliation(s)
- Jose de la Cruz
- Cornea and Refractive Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
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Hamam RN, Noureddin B, Salti HI, Haddad R, Khoury JM. Recalcitrant Post-LASIK Mycobacterium chelonae Keratitis Eradicated after the Use of Fourth-Generation Fluoroquinolone. Ophthalmology 2006; 113:950-4. [PMID: 16647126 DOI: 10.1016/j.ophtha.2006.02.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Revised: 02/15/2006] [Accepted: 02/15/2006] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To report a patient with Mycobacterium chelonae keratitis after LASIK and discuss therapeutic measures. DESIGN Interventional case report and literature review. INTERVENTION A healthy, 25-year-old man presented 6 weeks after LASIK with infectious keratitis in the left eye. Scrapings were obtained from the central stromal bed after lifting the flap and inoculated on culture media. MAIN OUTCOME MEASURES Response to medical treatment. RESULTS Mycobacterium chelonae was identified from stromal bed scrapings. The protracted course of the infection necessitated surgical debridement and flap amputation with slow and suboptimal response to prolonged (14 weeks) treatment with topical amikacin 3.3%, clarithromycin 1%, and levofloxacin 0.5%. The substitution of levofloxacin 0.5% with gatifloxacin 0.3% resulted in closure of the epithelial defect within 1 week and resolution of the infiltrates in 3 weeks. The combined regimen of gatifloxacin 0.3%, amikacin 3.3%, and clarithromycin 1% was continued for a total of 4 months. The patient remains infection free 1 year after stopping all antibiotics. CONCLUSION Treatment of post-LASIK nontuberculous mycobacteria remains a challenge. Institution of combination therapy including fortified amikacin, clarithromycin 1%, and a fourth-generation fluoroquinolone appeared to be beneficial in this patient.
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Affiliation(s)
- Rola N Hamam
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
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Rodriguez B, Holzinger KA, Le LH, Winkle RK, Allen RD. Mycobacterium chelonae keratitis after laser-assisted subepithelial keratectomy. J Cataract Refract Surg 2006; 32:1059-61. [PMID: 16814072 DOI: 10.1016/j.jcrs.2006.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 11/09/2006] [Indexed: 11/23/2022]
Abstract
A 24-year-old man with myopic astigmatism had uncomplicated laser-assisted subepithelial keratectomy (LASEK) in October 2004. Approximately 4 weeks later, a foreign-body sensation and redness developed in the left eye. A paracentral anterior stromal infiltrate was observed, and Gram stain on the day of presentation showed branching filamentous gram-positive rods. Cultures subsequently grew Mycobacterium chelonae. Topical tobramycin 15 mg/mL, azithromycin 2 mg/mL, amikacin 25 mg/mL, and cefazolin 50 mg/mL were initiated based on Gram stain results. We believe this is the first documented case of M chelonae keratitis after LASEK.
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Affiliation(s)
- Brandon Rodriguez
- Tripler Army Medical Center, Department of Ophthalmology, Honolulu, Hawaii 96789, USA
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Abstract
PURPOSE To demonstrate the feasibility of performing epi-LASIK after amputation of a LASIK flap. METHODS Three months following complicated primary LASIK and immediate flap amputation, a Lasitome microkeratome (Gebauer, Neuhausen, Germany), equipped with an epi-head and -blade, was used to perform an epi-LASIK surface ablation. RESULTS Despite uneven stromal contour at the site of the original hinge after amputation of the LASIK flap, the microkeratome passage was uneventful, resulting in a regular epithelial flap. Laser ablation was performed and the epithelial flap was repositioned. CONCLUSIONS Epi-LASIK was completed with no intraoperative complication in the presence of an irregular stromal surface after amputation of a LASIK flap. This procedure may extend our options in the management of LASIK flap-related complications.
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Affiliation(s)
- Suphi Taneri
- Zentrum fuer Refraktive Chirurgie Muenster, Muenster, Germany.
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Donnenfeld ED, Kim T, Holland EJ, Azar DT, Palmon FR, Rubenstein JB, Daya S, Yoo SH. ASCRS White Paper. J Cataract Refract Surg 2005; 31:2008-11. [PMID: 16338575 DOI: 10.1016/j.jcrs.2005.10.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2005] [Indexed: 11/29/2022]
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Patel NR, Reidy JJ, Gonzalez-Fernandez F. Nocardia keratitis after laser in situ keratomileusis: Clinicopathologic correlation. J Cataract Refract Surg 2005; 31:2012-5. [PMID: 16338576 DOI: 10.1016/j.jcrs.2005.02.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2005] [Indexed: 11/17/2022]
Abstract
A case of Nocardia asteroides keratitis occurring 3 weeks after laser in situ keratomileusis (LASIK) in a nontraumatized eye is reported. The patient presented with decreased vision, inflammation, and stromal melting of the LASIK flap, discrete infiltrates, and an anterior chamber cellular reaction. Cultures for acid-fast bacteria grew Nocardia asteroides after 5 days. Infection progressed despite treatment with topical antibiotics and eventually required penetrating keratoplasty (PKP). Postoperatively, the patient was placed on moxifloxacin, a fourth-generation flouroquinolone. The patient experienced a recurrence of Nocardia keratitis at the graft-host interface 2 months after the PKP. This eventually resolved with a combination of topical moxifloxacin and imipenem therapy.
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Affiliation(s)
- Nisha R Patel
- Departments of Ophthalmology, Ross Eye Institute, Buffalo, New York, USA
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Höfling-Lima AL, de Freitas D, Sampaio JLM, Leão SC, Contarini P. In Vitro Activity of Fluoroquinolones Against Mycobacterium abscessus and Mycobacterium chelonae Causing Infectious Keratitis After LASIK in Brazil. Cornea 2005; 24:730-4. [PMID: 16015094 DOI: 10.1097/01.ico.0000154411.07315.0a] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the in vitro activity of fluoroquinolones against Mycobacterium abscessus and Mycobacterium chelonae isolated from outbreaks of infectious keratitis in Brazil. MATERIAL AND METHODS Micobacterial isolates were recovered from infectious keratitis cases related outbreaks that occurred in Brazil after LASIK for myopia. Two outbreaks occurred in Rio de Janeiro in 1998 and 1999, and 3 in São Paulo between 2000 and 2003. All laboratorial analysis, including molecular identification and antibiotic susceptibility testing with determination of the minimum inhibitory concentration (MIC) levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin, were performed at Universidade Federal de São Paulo in Brazil. RESULTS Fifteen samples were identified as M. chelonae, and 3 were identified as M. abscessus. The outbreaks studied were designated SP-1 in 2000; SP-2 in 2000-2001; and SP-3 in 2003, R1 in 1988 and R2 in 1999. All but 1 of the M. chelonae were resistant to all fluoroquinolones with an MIC90 greater than 32 microg/mL. The only susceptible isolate had MIC levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin of 0.38 microg/mL, 0.032 microg/mL, 0.047 microg/mL, and 0.19 microg/mL, respectively. MIC levels for all 3 M. abscessus isolates tested were greater then 32 microg/mL for all fluoroquinolones tested. CONCLUSIONS Fluoroquinolone MICs for 17 M. abscessus and M. chelonae isolates recovered from infectious keratitis cases in Brazil indicate that they are not susceptible to these drugs in vitro. Further studies to investigate the in vivo effectiveness of fluoroquinolones against mycobacteria are required because in vitro tests do not support their use in the treatment of micobacterial keratitis in this particular geographic area.
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Abstract
PURPOSE We present a case of Mycobacterium keratitis after laser in situ keratomileusis (LASIK). METHOD A retrospective case report. RESULTS A 40-year-old woman developed Mycobacterium chelonae keratitis in the right eye 2 weeks after bilateral LASIK. The diagnosis was made by acid-fast staining of corneal scrapings on admission and confirmed by culture results 2 weeks later. Intensive treatment with topical amikacin (25 mg/mL) and ciprofloxacin and partial excision of the flap led to resolution of the infection after 2 months of therapy. In addition, topical methylprednisolone (1 mg/mL) was necessary to control inflammation and pain. No recurrence was found during the 1-year follow-up period. The final uncorrected and corrected visual acuity in the right eye was 20/25 and 20/20, respectively. CONCLUSION Mycobacterium keratitis is a potentially vision-threatening complication after LASIK. Early recognition of the organisms and aggressive treatment if infection develops may improve the outcome. When surgery is indicated, partial flap amputation, which may help to resolve the infection and preserve better vision, may be considered.
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Affiliation(s)
- Kai-Shiang Yang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China
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John T, Velotta E. Nontuberculous (atypical) mycobacterial keratitis after LASIK: current status and clinical implications. Cornea 2005; 24:245-55. [PMID: 15778593 DOI: 10.1097/01.ico.0000151565.63107.64] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Corneal infection with unfamiliar organisms such as nontuberculous (atypical) mycobacteria after laser in situ keratomileusis (LASIK) can be a significant clinical problem, and mismanagement of such corneal infection in an otherwise healthy, young individual can lead to significant medicolegal issues for the refractive surgeon. Because nontuberculous (atypical) mycobacterial keratitis is the most common infection after LASIK, the refractive surgeon should be aware of all aspects of this dreaded infection to be better prepared to manage such cases. METHODS Literature search. RESULTS/CONCLUSIONS This article provides a comprehensive compilation of all reported cases of nontuberculous (atypical) mycobacterial keratitis in the English literature and provides some useful recommendations for the clinical management of such corneal infection after LASIK.
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Affiliation(s)
- Thomas John
- Department of Ophthalmology, Loyola University at Chicago, Maywood, IL, USA.
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Tehrani M, Dick HB, Daeschlein G, Kramer A. Mikrobielle Keratitis nach Laser-in-situ-Keratomileusis. Ophthalmologe 2005; 102:514-9. [PMID: 15503051 DOI: 10.1007/s00347-004-1127-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Laser in situ keratomileusis (LASIK) is an effective option and currently one of the most commonly applied surgical techniques in the correction of refractive errors such as myopia, hyperopia, and astigmatism. In contrast to photorefractive keratectomy, it maintains the integrity of Bowman's membrane and the epithelium leading to faster visual rehabilitation as well as less pain and discomfort. Nevertheless, following LASIK the stroma is exposed to infectious organisms. Sight-threatening complications after LASIK are reported to be as rare as 1 in 1000 procedures. However, any infectious keratitis remains potentially devastating. Reports about infectious keratitis following LASIK have increasingly surfaced in recent years. We present a review of the literature on microbial keratitis and present our own cases and recommendations for possible prophylaxis and therapy.
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MESH Headings
- Adult
- Anti-Bacterial Agents/therapeutic use
- Antifungal Agents/therapeutic use
- Diagnosis, Differential
- Eye Infections/diagnosis
- Eye Infections/drug therapy
- Eye Infections/etiology
- Eye Infections/microbiology
- Eye Infections/prevention & control
- Eye Infections, Bacterial/diagnosis
- Eye Infections, Bacterial/drug therapy
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/microbiology
- Eye Infections, Bacterial/prevention & control
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/drug therapy
- Eye Infections, Fungal/etiology
- Eye Infections, Fungal/microbiology
- Eye Infections, Fungal/prevention & control
- Humans
- Incidence
- Keratitis/diagnosis
- Keratitis/drug therapy
- Keratitis/etiology
- Keratitis/microbiology
- Keratitis/prevention & control
- Keratitis, Herpetic/diagnosis
- Keratitis, Herpetic/etiology
- Keratomileusis, Laser In Situ/adverse effects
- Postoperative Care
- Postoperative Complications/diagnosis
- Postoperative Complications/drug therapy
- Postoperative Complications/prevention & control
- Preoperative Care
- Risk Factors
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31
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Kuehne JJ, Yu ALT, Holland GN, Ramaswamy A, Taban R, Mondino BJ, Yu F, Rayner SA, Giese MJ. Corneal pharmacokinetics of topically applied azithromycin and clarithromycin. Am J Ophthalmol 2004; 138:547-53. [PMID: 15488779 DOI: 10.1016/j.ajo.2004.04.071] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2004] [Indexed: 11/22/2022]
Abstract
PURPOSE To determine corneal levels of topically administered azithromycin and clarithromycin in a rabbit model. DESIGN Experimental animal study. METHODS Corneas of New Zealand albino rabbits were treated with topical azithromycin (2 mg/ml or 4 mg/ml) or clarithromycin (10 mg/ml). Topical azithromycin was prepared from an intravenous solution and topical clarithromycin from a suspension for oral use. All rabbits received one drop every 2 hours on the right eye. Groups of rabbits were treated for the following intervals: 6, 12, 24, and 48 hours (four rabbits for each combination of time point, drug, and dose). Corneal tissue was removed 1 hour after the last application. To investigate stability of tissue azithromycin levels, an additional group of four rabbits was treated for 24 hours, but corneal tissue was not removed until 24 hours later. Samples were homogenized, and drug concentrations were measured using high-pressure liquid chromatography (HPLC) analysis and bioactivity assay. RESULTS Corneal concentrations of azithromycin increased with drug dosage and duration of application. Rabbits treated with azithromycin tolerated the drug well without signs of irritation. Clarithromycin was undetectable in corneal tissue by HPLC and bioactivity assay for all rabbits. Some rabbits treated with clarithromycin had signs of ocular surface irritation. CONCLUSION Measurable concentrations of azithromycin are achieved in corneal tissue after topical application in a rabbit model, and the drug is well tolerated. Azithromycin may be a useful antibiotic for the topical treatment of human corneal infections, but clarithromycin, in currently available formulations, may not be effective because of poor tissue penetration.
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Affiliation(s)
- Jonas J Kuehne
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, and Department of Ophthalmology, David Geffen School of Medicine at UCLA, 90095-7003, USA
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Ferrer C, Rodríguez-Prats JL, Abad JL, Alió JL. Unusual anaerobic bacteria in keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2004; 30:1790-4. [PMID: 15313309 DOI: 10.1016/j.jcrs.2003.11.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2003] [Indexed: 11/28/2022]
Abstract
Laser in situ keratomileusis (LASIK) was performed in the left eye of a 57-year-old man for residual ametropia after phacoemulsification. The patient was given topical tobramycin and a corticosteroid for 1 week postoperatively. Fifteen days later, he developed 3 corneal infiltrates beneath the flap with a gas bubble, suggesting an anaerobic infection. Tobramycin and ofloxacin were administered every 2 hours, but the condition worsened. Corneal scrapings were taken from beneath the flap for microbiological cultures and a polymerase chain reaction (PCR) test. The PCR amplification was negative for fungi and mycobacteria and positive for bacterial DNA. Sequence analysis showed Propionibacterium granulosum as the causal agent, but cultures were negative. Treatment with vancomycin and cefazolin led to clinical improvement, with resolution of corneal infiltrates. Anaerobic microorganisms can cause keratitis after LASIK. Polymerase chain reaction amplification and DNA typing can help detect microorganisms involved in these ocular infections.
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Affiliation(s)
- Consuelo Ferrer
- Departmento Biología Molecular, Instituto Oftalmológico de Alicante, Avenida de Denia no 111, 03015 Alicante, Spain.
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Chang MA, Jain S, Azar DT. Infections following laser in situ keratomileusis: an integration of the published literature. Surv Ophthalmol 2004; 49:269-80. [PMID: 15110665 DOI: 10.1016/j.survophthal.2004.02.007] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Infections occurring after laser in situ keratomileusis (LASIK) surgery are uncommon, but the number of reports have steadily increased in recent years. This systematic, comprehensive review and analysis of the published literature has been performed in order to develop an integrative perspective on these infections. We have stratified the data by potential associations, microbiology, treatment, and the degree of visual loss, using Fisher's exact tests and Student's t-tests for analysis. In this review, we found that Gram-positive bacteria and mycobacterium were the most common causative organisms. Type of postoperative antibiotic and steroid use was not associated with particular infecting organisms or severity of visual loss. Gram-positive infections were more likely to present less than 7 days after LASIK, and they were associated with pain, discharge, epithelial defects, and anterior chamber reactions. Fungal infections were associated with redness and tearing on presentation. Mycobacterial infections were more likely to present 10 or more days after LASIK surgery. Moderate or severe visual reductions in visual acuity occurred in 49.4% of eyes. Severe reductions in visual acuity were significantly more associated with fungal infections. Flap lift and repositioning preformed within 3 days of symptom onset may be associated with better visual outcome.
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Affiliation(s)
- Margaret A Chang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Muñoz G, Alió JL, Pérez-Santonja JJ, Artola A, Abad JL. Ulcerative keratitis caused by Serratia marcescens after laser in situ keratomileusis. J Cataract Refract Surg 2004; 30:507-12. [PMID: 15030851 DOI: 10.1016/s0886-3350(03)00651-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2003] [Indexed: 10/26/2022]
Abstract
We report 2 cases of severe corneal infections caused by Serratia marcescens after laser in situ keratomileusis (LASIK). Twenty-four hours after LASIK, 2 patients developed infectious keratitis, 1 bilaterally. In each eye, the corneal flap was edematous, ulcerated, and detached from the stromal bed. Treatment included removal of the necrotic flap and aggressive antibiotic therapy. Cultures from corneal exudates were positive for S marcescens. After 1 year, both patients had a loss of best corrected visual acuity (BCVA) ranging from 20/40 to 20/22 because of irregular astigmatism. Overrefraction with a hard contact lens resulted in a BCVA of 20/20 in the 3 affected eyes. Slitlamp examination showed trace subepithelial haze without severe corneal scarring. Videokeratography disclosed areas of paracentral inferior steepening resembling keratoconus. Refraction and videokeratography remained stable after 6 months of follow-up. Ulcerative keratitis caused by S marcescens is a potential complication of LASIK. Bilateral involvement may occur if bilateral simultaneous surgery is performed.
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Affiliation(s)
- Gonzalo Muñoz
- Refractive Surgery Department, Instituto Oftalmológico de Alicante, and Division of Ophthalmology, Miguel Hernández University, Alicante, Spain.
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Affiliation(s)
- Scott D Barnes
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Cornea and Refractive Surgery Service, Boston 02114, USA
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Winthrop KL, Steinberg EB, Holmes G, Kainer MA, Werner SB, Winquist A, Vugia DJ. Epidemic and sporadic cases of nontuberculous mycobacterial keratitis associated with laser in situ keratomileusis. Am J Ophthalmol 2003; 135:223-4. [PMID: 12566028 DOI: 10.1016/s0002-9394(02)01955-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To report national case-finding results for nontuberculous mycobacterial keratitis and describe its association with laser in situ keratomileusis (LASIK). DESIGN Enhanced passive disease reporting. METHODS In April 2001, we investigated a California cluster of Mycobacterium chelonae keratitis associated with hyperopic LASIK using a contact lens mask. To identify other possibly related cases, the American Academy of Ophthalmology e-mailed its members asking them to report recent cases of nontuberculous mycobacterial keratitis to the Centers for Disease Control and Prevention. RESULTS Forty-three additional cases of keratitis were reported (onsets between August 2000 and June 2001). Of these, 31 occurred as part of two unrelated LASIK-associated outbreaks. The 12 other reported cases occurred in sporadic fashion. Of the latter cases, 4 were associated with LASIK surgery. None of the reported cases were related to the M. chelonae cluster in California. CONCLUSIONS Laser in situ keratomileusis-associated keratitis with nontuberculous mycobacteria may be more common than previously known.
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Affiliation(s)
- Kevin L Winthrop
- Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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