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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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Ledbetter EC, Schlesener BN, Demeter EA. Nocardia and Streptomyces keratitis in dogs: In vivo detection of filamentous bacteria by confocal microscopy. Vet Ophthalmol 2023; 26:211-218. [PMID: 36840607 DOI: 10.1111/vop.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE To describe the clinical features of dogs with Nocardia and Streptomyces keratitis, including the results of in vivo confocal microscopy examinations. ANIMAL STUDIED A 15-year-old, male-castrated, miniature Schnauzer was presented with a multilobulated, cystic, pink, ulcerated corneal mass with surrounding dense leukocyte infiltrates. Cytologic evaluation of a corneal scraping identified pyogranulomatous inflammation and filamentous bacteria. Nocardia nova was cultured from corneal samples. Anterior lamellar keratectomy was performed to excise the affected corneal region and histopathologic evaluation confirmed the diagnosis of pyogranulomatous keratitis. A 10-year-old, male-castrated, Yorkshire terrier was presented for evaluation of a chronic anterior stromal corneal ulcer associated with a brown corneal plaque. Cytologic evaluation of a corneal scraping identified suppurative inflammation and filamentous bacteria. A Streptomyces sp. was cultured from corneal samples. The keratitis in both dogs resolved with therapy. PROCEDURES In vivo confocal microscopy examination of the corneal lesions in both dogs revealed dense accumulations of leukocytes and clusters of hyperreflective, slender, branching bacterial structures that were approximately 1.5-2.0 μm in diameter and 25-50 μm in length. Confocal microscopy imaging of the Nocardia isolate in vitro, and ex vivo canine corneas experimentally infected with the bacteria, was performed to corroborate the in vivo findings. The morphology of the filamentous bacteria was similar between the in vivo, in vitro, and ex vivo confocal microscopy examinations. CONCLUSIONS AND CLINICAL RELEVANCE Nocardia and Streptomyces spp. can be associated with infectious keratitis in dogs. In vivo detection of filamentous bacteria in the cornea can be accomplished by confocal microscopy.
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Affiliation(s)
- Eric C Ledbetter
- From the Departments of Clinical Sciences and Biomedical Sciences, Cornell University, Ithaca, New York, USA
| | - Brittany N Schlesener
- From the Departments of Clinical Sciences and Biomedical Sciences, Cornell University, Ithaca, New York, USA
| | - Elena A Demeter
- College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
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Adre E, Maestre-Mesa J, Durkee H, Arboleda A, Flynn H, Amescua G, Parel JM, Miller D. Nocardia keratitis: amikacin nonsusceptibility, risk factors, and treatment outcomes. J Ophthalmic Inflamm Infect 2022; 12:11. [PMID: 35247126 PMCID: PMC8898206 DOI: 10.1186/s12348-022-00287-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To report the increasing trends in Nocardia keratitis species diversity and in vitro antibiotic susceptibility, to demonstrate contact lens wear as a risk factor, and to report visual acuity outcomes after treatment. METHODS A retrospective clinical case series was performed at a single academic referral center which identified 26 patients with culture-confirmed Nocardia keratitis between 2014 and 2021. A combination of conventional microbiology and molecular techniques were used to identify isolates. Antibiotic susceptibilities were determined using both commercial and in-house laboratory methods. Microbiology and electronic medical records were used to characterize patients' clinical profiles. RESULTS Patients' median age was 32.5 years with a 2:1 male to female ratio. Eighty-four percent (n = 21/25) of patients were diagnosed within two weeks of symptom onset. Nocardia amikacinitolerans (n = 11/26) was the most recovered Nocardia isolate among study patients. Sixty-four percent (n = 16/25) of all isolates, including all 11 N. amikacinitolerans isolates, were resistant to amikacin. All isolates were susceptible to trimethoprim sulfamethoxazole. Contact lens wear was the leading identified risk factor (n = 23/26) in this population. Median time to resolution was 44 days (n = 23, range: 3-190 days). Seventy-one percent of patients (n = 15/21) had a final visual acuity of 20/40 or better. CONCLUSION Amikacin resistant Nocardia isolates were the majority in the current study. Trimethoprim sulfamethoxazole may be the preferred alternative antibiotic treatment based on in vitro susceptibilities. Contact lens wear was the major risk factor for Nocardia keratitis in South Florida. Overall visual acuity treatment outcomes of patients were favorable.
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Affiliation(s)
- Ethan Adre
- University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jorge Maestre-Mesa
- Ocular Microbiology Laboratory, Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, McKnight Research Pavilions, Rm 103A,1638 NW 10th Avenue, Miami, FL, 33136, USA.,Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heather Durkee
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alejandro Arboleda
- University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology University of Miami Miller School of Medicine, Miami, FL, USA
| | - Harry Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Guillermo Amescua
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean-Marie Parel
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darlene Miller
- Ocular Microbiology Laboratory, Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, McKnight Research Pavilions, Rm 103A,1638 NW 10th Avenue, Miami, FL, 33136, USA. .,Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.
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Adre E, Durkee H, Arboleda A, Alawa K, Maestre J, Mintz KJ, Leblanc RM, Amescua G, Parel JM, Miller D. Rose Bengal and Riboflavin Mediated Photodynamic Antimicrobial Therapy Against Selected South Florida Nocardia Keratitis Isolates. Transl Vis Sci Technol 2022; 11:29. [PMID: 35044443 PMCID: PMC8787600 DOI: 10.1167/tvst.11.1.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To examine and compare the efficacy of in vitro growth inhibition using rose bengal and riboflavin photodynamic antimicrobial therapy (PDAT) for Nocardia keratitis isolates. Methods Nocardia asteroides complex, Nocardia amikacinitolerans, and Nocardia farcinica species were isolated from patients with confirmed Nocardia keratitis. Isolates were tested against three experimental groups: (1) no photosensitizer/no irradiation, (2) photosensitizer/no irradiation, and (3) photosensitizer/irradiation. Each isolate was prepared in suspension to a concentration of 1.5 × 108 CFU/mL. Bacterial suspensions were mixed with water or prepared 0.1% photosensitizer solution for a final bacterial concentration of 1.5 × 107 CFU/mL. Aliquots of 1 mL were plated on 5% sheep blood agar. Rose bengal and riboflavin PDAT plates were irradiated for 15 minutes with a 525- or 375-nm custom 6-mW/cm2 powered light source for a total fluence of 5.4 J/cm2. All experimental groups were repeated in triplicate. Plates were incubated in a 35°C non-CO2 incubator for 96 hours and photographed. Percent inhibition was evaluated using LabVIEW-based software. Results All strains of Nocardia tested with 0.1% rose bengal and irradiated for 15 minutes demonstrated statistically significant inhibition of growth (P < 0.05). No other experimental groups displayed any bacterial inhibition. Conclusions Rose bengal is superior to riboflavin PDAT against selected Nocardia isolates. In vivo testing is warranted to investigate the utility of rose bengal PDAT for severe Nocardia keratitis. Translational Relevance In vitro results for three clinical strains of Nocardia support the possible use of rose bengal PDAT as a complementary treatment of Nocardia keratitis.
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Affiliation(s)
- Ethan Adre
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heather Durkee
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
| | - Alejandro Arboleda
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Karam Alawa
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jorge Maestre
- Ocular Microbiology Laboratory, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Keenan J Mintz
- Department of Chemistry, College of Arts and Science, University of Miami, Coral Gables, FL, USA
| | - Roger M Leblanc
- Department of Chemistry, College of Arts and Science, University of Miami, Coral Gables, FL, USA
| | - Guillermo Amescua
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean-Marie Parel
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA.,Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darlene Miller
- Ocular Microbiology Laboratory, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Soleimani M, Masoumi A, Khodavaisy S, Heidari M, Haydar AA, Izadi A. Current diagnostic tools and management modalities of Nocardia keratitis. J Ophthalmic Inflamm Infect 2020; 10:36. [PMID: 33263838 PMCID: PMC7710777 DOI: 10.1186/s12348-020-00228-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022] Open
Abstract
Nocardia species are an uncommon but important cause of keratitis. The purpose of this review is to discus previous published papers relation to the epidemiology, etiology, diagnosis and management of Nocardia keratitis. Nocardia asteroides is the most frequently reported from Nocardia keratitis. Pain, photophobia, blepharospasm and lid swelling are mainly clinical manifestations. Usual risk factors for Nocardia keratitis are trauma, surgery, corticosteroids, and contact lens wear. Several antibiotics were used for treatment of Nocardia infection but according to studies, topical amikacin is the drug of choice for Nocardia keratitis. Topical steroid should not prescribe in these patients. In conclusion, although Nocardia keratitis is rare, early diagnosis and treatment are essential to prevent any scar formation and preserve a good visual acuity.
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Affiliation(s)
- Mohammad Soleimani
- Ocular Trauma and Emergency Department, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Masoumi
- Ocular Trauma and Emergency Department, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sadegh Khodavaisy
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Heidari
- Ocular Trauma and Emergency Department, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali A Haydar
- Ocular Trauma and Emergency Department, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Izadi
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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Martínez-Barricarte R. Isolated Nocardiosis, an Unrecognized Primary Immunodeficiency? Front Immunol 2020; 11:590239. [PMID: 33193422 PMCID: PMC7606290 DOI: 10.3389/fimmu.2020.590239] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/31/2020] [Indexed: 01/19/2023] Open
Abstract
Nocardiosis is an infectious disease caused by the gram-positive bacterium Nocardia spp. Although it is commonly accepted that exposure to Nocardia is almost universal, only a small fraction of exposed individuals develop the disease, while the vast majority remain healthy. Nocardiosis has been described as an "opportunistic" disease of immunocompromised patients, suggesting that exposure to the pathogen is necessary, but a host predisposition is also required. Interestingly, increasing numbers of nocardiosis cases in individuals without any detected risk factors, i.e., without overt immunodeficiency, are being reported. Furthermore, a growing body of evidence have shown that selective susceptibility to a specific pathogen can be caused by a primary immunodeficiency (PID). This raises the question of whether an undiagnosed PID may cause nocardiosis affecting otherwise healthy individuals. This review summarizes the specific clinical and microbiological characteristics of patients with isolated nocardiosis published during the past 30 years. Furthermore, it gives an overview of the known human immune mechanisms to fend off Nocardia spp. obtained from the study of PIDs and patients under immunomodulatory therapies.
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Affiliation(s)
- Rubén Martínez-Barricarte
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Pathology, Microbiology, and Immunology, Vanderbilt Center for Immunobiology, Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN, United States
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Abstract
Background:In microbial keratitis, infection of the cornea can threaten vision through permanent corneal scarring and even perforation resulting in the loss of the eye. A literature review was conducted by Karsten, Watson and Foster (2012) to determine the spectrum of microbial keratitis. Since this publication, there have been over 2600 articles published investigating the causative pathogens of microbial keratitis.Objective:To determine the current spectrum of possible pathogens implicated in microbial keratitis relative to the 2012 study.Methods:An exhaustive literature review was conducted of all the peer-reviewed articles reporting on microbial pathogens implicated in keratitis. Databases including MEDLINE, EMBASE, Scopus and Web of Science were searched utilising their entire year limits (1950-2019).Results:Six-hundred and eighty-eight species representing 271 genera from 145 families were implicated in microbial keratitis. Fungal pathogens, though less frequent than bacteria, demonstrated the greatest diversity with 393 species from 169 genera that were found to cause microbial keratitis. There were 254 species of bacteria from 82 genera, 27 species of amoeba from 11 genera, and 14 species of virus from 9 genera, which were also identified as pathogens of microbial keratitis.Conclusion:The spectrum of pathogens implicated in microbial keratitis is extremely diverse. Bacteria were most commonly encountered and in comparison, to the review published in 2012, further 456 pathogens have been identified as causative pathogens of microbial keratitis. Therefore, the current review provides an important update on the potential spectrum of microbes, to assist clinicians in the diagnosis and treatment of microbial keratitis.
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Infectious crystalline keratopathy. Surv Ophthalmol 2017; 63:480-499. [PMID: 29097211 DOI: 10.1016/j.survophthal.2017.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 10/15/2017] [Accepted: 10/19/2017] [Indexed: 01/07/2023]
Abstract
Infectious crystalline keratopathy was first reported by Gorovoy and colleagues in 1983 when they identified bacteria colonizing a cornea after a penetrating keratoplasty. Subsequent cases have elaborated on the organisms responsible and the management outcomes. Patients present with a white or gray branching opacity originating from an epithelial defect, commonly after a penetrating keratoplasty. Local immunosuppression contributes to the quiescent nature and the limited inflammatory response associated with infectious crystalline keratopathy. Diagnosis of the infective pathogens may be difficult, with a corneal scraping often being too superficial to obtain an adequate specimen. A biofilm is present that advantages microorganism survival, reduces antibiotic bioavailability, and inhibits diagnostic microbial detection. Treatment begins with topical antimicrobials, initially broad spectrum and then targeted to microorganism sensitivity. Adjunctive therapies to enhance the efficacy of treatment include disruption of the microorganism biofilm by laser, intrastromal antibiotics, and keratectomy. In recalcitrant cases, or where corneal scarring ensues, corneal transplantation is required.
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