Endophthalmitis Caused byMycobacterium Abscessus

Nontuberculous mycobacterial endophthalmitis: case series and review of literature

Background

To report three cases of nontuberculous mycobacterial (NTM) endophthalmitis following multiple ocular surgeries and to review previous literature in order to study the clinical profile, treatment modalities, and visual outcomes among patients with NTM endophthalmitis.

Methods

Clinical manifestation and management of patients with NTM endophthalmitis in the Department of Ophthalmology, Faculty of Medicine, Siriraj hospital, Mahidol University, Bangkok, Thailand were described. In addition, a review of previously reported cases and case series from MEDLINE, EMBASE, and CENTRAL was performed. The clinical information and type of NTM from the previous studies and our cases were summarized.

Results

We reported three cases of NTM endophthalmitis caused by M. haemophilum, M. fortuitum and M. abscessus and a summarized review of 112 additional cases previously published. Of 115 patients, there were 101 exogenous endophthalmitis (87.8%) and 14 endogenous endophthalmitis (12.2%). The patients’ age ranged from 13 to 89 years with mean of 60.5 ± 17.7 years with no gender predominance. Exogenous endophthalmitis occurred in both healthy and immunocompromised hosts, mainly caused by cataract surgery (67.3%). In contrast, almost all endogenous endophthalmitis patients were immunocompromised. Among all patients, previous history of tuberculosis infection was identified in 4 cases (3.5%). Rapid growing NTMs were responsible for exogenous endophthalmitis, while endogenous endophthalmitis were commonly caused by slow growers. Treatment regimens consisted of macrolides, fluoroquinolones or aminoglycosides, which were continued for up to 12 months. Initial and final vision were generally worse than 6/60.

Conclusions

NTM endophthalmitis is a serious intraocular infection that leads to irreversible loss of vision. The presentation can mimic a chronic recurrent or persistent intraocular inflammation. History of multiple intraocular surgeries or immune-deficiency in patient with chronic panuveitis should raise the practioner’s suspicion of NTM endophthalmitis. Appropriate diagnosis and treatment are important to optimize visual outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05606-2.

Endophthalmitis caused by Mycobacterium houstonense: case report

BACKGROUND

Mycobacterium houstonense is rapidly growing mycobacteria (RGM) that belongs to M. fortuitum group. So far, there have been few associated reports of human diseases induced by M. houstonense worldwide.

CASE PRESENTATION

We present a delayed-onset postoperative endophthalmitis caused by M. houstonense after glaucoma drainage implant (GDI) surgery. The ocular infection lasted for 2 months without appropriate treatment that developed into endophthalmitis and the patient underwent an emergency enucleation.

CONCLUSION

Implant erosion and a delay in diagnosis of ocular infection could lead to irreversible damage as observed in our case. Ophthalmologists should be alert for ocular RGM infection, and prompt laboratory diagnosis with initiation of effective multidrug therapy might prevent loss of vision.

Postoperative Mycobacteroides abscessus subsp. abscessus endophthalmitis: Clinical analysis of 12 clustered adults and a proposed therapeutic algorithm

PURPOSE

Postoperative endophthalmitis caused by nontuberculous mycobacterium is a rare but devastating complication after intraocular surgery. However, optimal treatment strategies remain undetermined in view of its rarity.

METHODS

We investigated the cases of culture-proven postoperative Mycobacteroides abscessus subsp. abscessus endophthalmitis in southern Taiwan, focusing on clinical manifestations and microbiological study, and aimed to describe clinical staging and to propose a therapeutic modality for this disease.

RESULTS

Twelve cases, including two published cases, were treated in two medical centers in southern Taiwan between Aug. 2011 and Dec. 2016, and all ever received cataract surgery at one clinic. Their disease courses could be categorized into four distinct stages, i.e., the initial, quiescent, recurrent, and end stage, and some cases experienced 1-4 cycles of quiescent-recurrent stages. Although all eyes ended up with phthisis or were eviscerated, the affected eyes receiving pars plana vitrectomy (PPV) tended to become quiescent and survived longer than those without PPV (adjusted hazard ratio: 13.9, p < 0.05). Eight isolates of eight patients were available for microbiological study. All isolates were susceptible to amikacin, and inducible clarithromycin resistance was observed in 100% of isolates.

CONCLUSION

Despite the preservation of vision in postoperative M.abscessus endophthalmitis remained a challenge, a stage-based approach is proposed, which may facilitate decision-makings for the future study.

A cluster of nontuberculous mycobacterial endophthalmitis (NTME) cases after cataract surgery: clinical features and treatment outcomes

PURPOSE

To report the clinical features and treatment outcomes in a cluster of patients with endophthalmitis after cataract surgery caused by nontuberculous mycobacterium.

PATIENTS AND METHODS

Retrospective chart review and noncomparative, consecutive case series. Nine consecutive cases of endophthalmitis, after cataract surgery in a local clinic, were referred to our hospital. The treatment outcomes and analysis of risk factors for infection are reported.

RESULTS

The major symptoms at presentation were pain, redness, and decreased vision. Best-corrected visual acuity at presentation ranged from hand motion in two cases (22%), counting fingers at 30 cm in three cases (33%), 20/100 in two cases (20%), 20/63 in one case (11%), to 20/50 in one (11%) case. The mean duration between cataract surgery to presentation at our hospital was 16.7 days. Prompt intravitreal injections (IVI) of amikacin (0.4 mg/0.1 mL) and vancomycin (1 mg/0.1 mL), with topical moxifloxacin were administered initially. Pars plana vitrectomy with amikacin (10 mg/L) and vancomycin (20 mg/L) intravitreal irrigation, and intraocular lens removal were performed for all patients. Systemic antibiotics including amikacin and tigecycline were prescribed for 10 days, and clarithromycin was prescribed for at least 3 months. In all the nine cases, the culture results from either aqueous tapping or vitrectomy sample were positive for nontuberculous Mycobacterium: Mycobacterium abscessus/chelonae, which was compatible with iatrogenic clustered infection. At the last follow-up, three cases (33.3%) had best-corrected visual acuity of counting fingers at 30 cm, while the other six cases had no light perception. Two cases (22%) were enucleated and one case (11%) had phthisis bulbi.

CONCLUSION

Nontuberculous mycobacterium endophthalmitis (NTME) often induces chronic recurrent or persistent intraocular inflammation. Very poor outcomes despite aggressive antibiotic treatment and repeated surgical interventions are suggestive of the virulent nature of the organisms. Autoclave sterilization and perioperative disinfection may help in reducing iatrogenic clustered infection.

Acute postcataract endophthalmitis at a referral center in northern Taiwan: Causative organisms, clinical features, and visual acuity outcomes after treatment: A retrospective cohort study

Acute-onset endophthalmitis after cataract surgery is a rare but serious complication. In this study, we identified the clinical profile of acute-onset endophthalmitis after cataract surgery using a retrospective review between January 1, 2009 and December 31, 2015 at a referral center in northern Taiwan. Twenty-five eyes of 25 patients with endophthalmitis were included; 60% were male. The mean age at diagnosis was 70.44 ± 1.66 years. The right eye was affected in 44% of patients. The mean time of cataract surgery to hospital was 12.76 ± 1.88 days. The mean time from the onset of endophthalmitis to hospital was 3.72 ± 0.78 days. Furthermore, 56% of patients received the immediate treatment of an intracameral or intravitreal injection of antibiotics at a clinic before referral. The mean initial visual acuity was 1.97 ± 0.15 logarithm of the minimum angle of resolution. The initial examination found corneal edema in 84% of patients, hypopyon in 48%, and vitritis in 88%. A total of 76% of patients underwent an initial treatment of pars plana vitrectomy and intraocular antibiotic injection (IOAI); 24% received an IOAI. The culture results of 52% (13/25) of patients were positive; 4 isolates were gram-positive, 8 were nontuberculosis Mycobacterium abscessus, and 1 was fungal. Thirteen of 25 patients had hypertension; 2 of 25 had diabetes mellitus. The mean follow-up time was 61.64 ± 8.27 days. Multiple factors influenced the final visual outcome of acute-onset endophthalmitis after cataract surgery. This study found that early referral for treatment could improve the final outcome. In addition, postcataract endophthalmitis caused by M abscessus recurs easily and has a worse visual outcome despite appropriate treatment.

Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature

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.

Rapid diagnosis of Mycobacterium abscessus endophthalmitis

Nontuberculous mycobacteria are widely distributed in the environment and have the potential to cause a wide spectrum of infections including pulmonary, bone, soft tissue or ocular infections. They are a rare cause of endophthalmitis, a potentially devastating condition, which may be acquired through contamination of water or antiseptic solutions. Diagnosis is often delayed due to low clinical suspicion, resulting in poor clinical outcomes. Newer laboratory techniques such as real-time PCR can be used for rapid detection, identification and speciation of mycobacteria and allow for initiation of focused antibiotic therapy. We describe a case of Mycobacterium abscessus endophthalmitis that developed 30 years after traumatic loss of cornea in a patient with diabetes mellitus.

Nontuberculous mycobacterial infection after clear corneal phacoemulsification cataract surgery: a report of 13 cases

PURPOSE

To review the patient profile, clinical presentation, management, and outcomes of nontuberculous mycobacterial (NTM) infection after clear corneal phacoemulsification.

METHODS

Review of consecutive cases diagnosed with NTM infection after phacoemulsification from 2004 to 2009. Demographic data, clinical characteristics, diagnosis, treatment, and outcomes were analyzed.

RESULTS

Thirteen eyes of 13 patients with mean age of 61.1 years, consisting of 7 men and 6 women were included. Twelve of 13 eyes (92%) underwent uncomplicated clear cornea phacoemulsification with posterior lens implant. Mean interval from surgery to onset of symptoms was 6.3 weeks, and time to referral ranged from 2 days to 9 months. Ten eyes (77%) presented with stromal wound abscess, whereas 3 (23%) appeared as iridocyclitis with posterior capsule plaques. Five eyes were clustered while the rest were isolated cases. All cases were culture positive for NTM. Two cases were treated medically, 3 had removal of lens implant and capsule, and 8 had penetrating keratoplasty with or without removal of lens implant, iridectomy, and/or pars plana vitrectomy. After a mean follow-up of almost 22 months, best-corrected visual acuity of 20/40 or better was achieved in half of the cases (54%). One case of recurrence was noted.

CONCLUSIONS

NTM infection should be suspected in patients presenting with corneal stromal wound abscess or iridocyclitis with posterior capsular plaques 6 to 7 weeks after phacoemulsification. Early diagnosis and treatment can lead to good outcomes, and management should include a combination of medical and surgical therapies.

Nontuberculous mycobacterial ocular and adnexal infections

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.

Uveitis with occult choroiditis due to Mycobacterium kansasii: limitations of interferon-gamma release assay (IGRA) tests (case report and mini-review on ocular non-tuberculous mycobacteria and IGRA cross-reactivity)

Ocular tuberculosis is difficult to diagnose but should be suspected when uveitis fails to respond to inflammation suppressive therapy. Interferon-gamma release assays (IGRAs) represent a substantial help to diagnose suspected ocular tuberculosis especially in non-endemic areas. Indocyanine green angiography (ICGA) is able to detect clinically silent choroiditis that, when associated with a positive IGRA test, should lead the clinician to suspect ocular tuberculosis, warranting specific therapy. The fact that IGRA tests can also react with some atypical strains of mycobacteria is not always known. We report here a case with resistant post-operative inflammation that presented with occult ICGA-detected choroiditis and a positive IGRA test that was most probably due to the non-tuberculous mycobacterium (NTM) Mycobacterium kansasii. A 66 year-old man presented with a resistant cystoid macular oedema (CMO) in his left eye after combined cataract and epiretinal membrane surgery. At entry, his best-corrected visual acuity (BCVA) was 0.5 for far and near OS. Intraocular inflammation measured by laser flare photometry was elevated in the left eye (54.4 ph/ms) and also in the right eye (50.9 ph/ms). Four subTenon's injections of 40 mg of triamcinolone did not produce any substantial improvement. Therefore a complete uveitis work-up was performed. Fluorescein angiography showed CMO OS and ICGA showed numerous hypofluorescent dots and fuzziness of choroidal vessels in both eyes. Among performed laboratory tests, the QuantiFERON®-TB Gold test was positive. After a pulmonological examination disclosing a right upper lobe infiltrate, the patient was started on a triple anti-tuberculous therapy. Bronchial aspirate, obtained during bronchoscopy, was Ziehl-positive and culture grew M. kansasii. Nine months later, BCVA OS increased to 1.0 and flare decreased to 40.2 ph/ms. The CMO OS resolved angiographically and did not recur with a macula still slightly thickened on OCT. Suspected ocular tuberculosis based on clinical findings and a positive IGRA test can, in rare instances, be due to atypical mycobacteria that also produce positive IGRA tests such as M. kansasii, M. szulgai, M. gordonae, M. flavescens and M. marinum. In our case failure to isolate the atypical mycobacterium would not have had negative therapeutic consequences, as M. kansasii is sensitive to the standard anti-tuberculous treatments, which is not the case with other NTMs.

Application of polymerase chain reaction-based restriction fragment length polymorphism in typing ocular rapid-growing nontuberculous mycobacterial isolates from three patients with postoperative endophthalmitis

PURPOSE

We describe postoperative endophthalmitis caused by rapid-growing nontuberculous mycobacteria (RGNTM) in 3 patients after small-incision cataract surgery with intraocular lens (IOL) implantation performed elsewhere and referred to us for management. Subsequent identification and confirmation was carried out with biochemical tests and polymerase chain reaction-based restriction fragment length polymorphism (PCR-RFLP).

MATERIALS AND METHODS

The corneal scraping and eviscerated material of the first patient, the corneal button and the IOL of the second patient, and the corneal scraping of the third patient were processed for routine bacteriologic studies including acid-fast bacilli (AFB) by smear (excepting the IOL) and culture. Subsequent identification of the RGNTM was carried out by using biochemical tests and PCR-RFLP by using primers targeting the heat shock protein 65 region of mycobacteria.

RESULTS

AFB smear was positive in all 3 patients. The corneal scraping of the first patient, the corneal button and IOL of the second patient, and the corneal scraping of the third patient were culture positive for RGNTM and were identified as Mycobacterium abscessus in the first and second patients and M. fortuitum sorbitol-positive third biovariant in the third patient.

CONCLUSIONS

A clinical suspicion of infection by RGNTM in delayed-onset postoperative endophthalmitis should be considered when resistance to standard therapy is encountered.

Mycobacterium abscessus: an emerging rapid-growing potential pathogen. Review article

Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant rapid-growing mycobacterium. It is commonly associated with contaminated traumatic skin wounds and with post-surgical soft tissue infections. It is also one of the mycobacteria that are most often isolated from cystic fibrosis patients. It is essential to differentiate this species from the formerly indistinct "M. chelonae-complex", as chemotherapy is especially difficult in M. abscessussenso strictu. Clarithromycin or azithromycin are the only regular oral antimycobacterial agents with an effect on M. abscessus, and should preferably be supplemented with other drugs since long-term monotherapy may cause resistance. Amikacin is a major parenteral drug against M. abscessus that should also be given in combination with another drug. The recently introduced drug tigecycline may prove to be an important addition to chemotherapy, but has yet to be fully clinically evaluated as an antimycobacterial agent. Surgery can be curative, or at least helpful, in the healing of M. abscessus infection, and if conducted, it should include the removal of all foreign or necrotic material. There is increasing awareness of M. abscessus as an emerging pathogen.