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Brevibacterium casei endophthalmitis after intravitreal dexamethasone implant
Endoftalmitis aguda por Brevibacterium casei tras implante intravítreo de dexametasona
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Olate-Pérez, R.A. Díaz-Céspedes, N. Ruíz-del-Río, D. Hernández-Pérez, A. Duch-Samper" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Olate-Pérez" "email" => array:1 [ 0 => "aolatep@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R.A." "apellidos" => "Díaz-Céspedes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Ruíz-del-Río" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "D." 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"apellidos" => "Duch-Samper" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Institut Clínic d’Oftalmología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital de Manises, Manises, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico Universitario, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endoftalmitis aguda por <span class="elsevierStyleItalic">Brevibacterium casei</span> tras implante intravítreo de dexametasona" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 690 "Ancho" => 2093 "Tamanyo" => 184779 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Images at 14 days of postoperative follow-up. a) Biomicroscopy: pigmented keratin precipitates. b) Fundoscopy: signs of retinal ischemia. c) Macular OCT: foveal atrophy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Brevibacterium casei</span> is an aerobic gram-positive bacillus. Its presence is described in raw milk, on the surface of cheese and on human skin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Scarcely pathogenic, few cases of infection have been published, these being mainly in immunosuppressed people.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the ophthalmological field only two cases of endophthalmitis have been reported, the first one endogenous<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the second one after vegetable trauma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> No endophthalmitis cases have been previously described after ophthalmological procedures.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A case of endophthalmitis secondary to <span class="elsevierStyleItalic">B. casei</span> after intravitreal therapy with dexamethasone implant in a patient with diabetic macular edema (DME) is presented.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinic case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 49-year-old man with a medical history of type 2 diabetes mellitus with poor metabolic control (glycosylated hemoglobin: 8.1%) despite insulin treatment. At the ophthalmological level, the patient presented moderate non-proliferative diabetic retinopathy and DME with foveal involvement in right eye (RE), refractory to 3 doses of intravitreal therapy with ranibizumab. For this reason it was decided to perform intravitreal injection with dexamethasone implant (Ozurdex; Allergan, California, USA) in RE. Seven days later he visited the emergency room with 24 -h pain, red eye and blurred vision in RE. Best corrected visual acuity (BCVA) decreased from 20/50 before the implant to hand movement. The scan showed conjunctival secretion, 4+ cells in the anterior chamber and 1 mm high hypopion. Fundoscopy was not possible, so an ocular ultrasound was performed, which showed opacities in vitreous.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Sampling was carried out in the conjunctiva, aqueous and vitreous humor for Gram and bacterial and fungal cultures, and later the intravitreal injection of vancomycin 1 mg/0.1 ml and ceftazidime 2 mg/0.1 ml, and it was continued with ambulatory management with topical mydriatics and moxifloxacin 5 mg/mL topical hourly and moxifloxacin 400 mg oral every 12 h.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After 48 h the patient reported worsening symptoms. BCVA was perception of light (PL). Biomicroscopy showed a 3.0 mm hypoxia. It was decided to perform surgery, which consisted of lensectomy, vitreous sampling for culture, <span class="elsevierStyleItalic">pars plana vitrectomy,</span> implant removal and intravitreal silicone oil injection. Hospital management with intravenous moxifloxacin was continued. During the period of admission, the patient evolved with stable hemodynamics, without fever and lower analgesic requirements, so it was decided to continue ambulatory treatment with oral and topical moxifloxacin, progressively decreasing its frequency.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After 14 days, the patient evolved without pain. Even so, BCVA was kept in PL. Biomicroscopy showed keratic precipitates, without cells in the anterior chamber. Fundoscopy showed fibrotic vessels and isolated hemorrhages that suggested retinal ischemia. Macular optical coherence tomography showed macular atrophy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The microbiology report certified that the sample, obtained during the surgery, showed gram-positive rods without motility and the blood agar culture, non-hemolytic whitish colonies, catalase-positive, so <span class="elsevierStyleItalic">Brevibacterium species</span> was suspected. Subsequently, this sample was evaluated by means of the API-Coryne System version 2.0 (bioMérieux, Marcy L'Étoile, France) commercial test which finally confirmed <span class="elsevierStyleItalic">B. casei</span> as the agent causing endophthalmitis. The antibiogram performed showed sensitivity to fourth generation fluoroquinolones, so treatment with topical and oral moxifloxacin was maintained until completing one month.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the subsequent systemic follow-up, carried out by the internal medicine service of our institution, diagnostic tests were requested to rule out acquired immunosuppression: hemogram, globular sedimentation rate and C-reactive protein, plasma electrolytes, renal function, hepatic laboratory, thyroid hormones, chest X-ray and Mantoux, serology for human immunodeficiency virus, rheumatoid factor, antinuclear antibodies, angiotensin converting enzyme, neutrophil antidote antibodies and electrocardiogram, all within normal or negative limits, according to the case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At the ophthalmological level, no reappearance of intraocular inflammation was evident after 3 months of follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Endophthalmitis following intravitreal therapy is a rare but potentially devastating complication, requiring prompt and timely management. It occurs more frequently when steroids are injected than with antiangiogens (0.13 versus 0.019).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The most frequently isolated germs in post-intravitreal endophthalmitis are gram-positive bacteria (91.3%), including coagulase negative <span class="elsevierStyleItalic">Staphylococcus</span> (78.3%).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">B. casei</span> is one of 45 species of the <span class="elsevierStyleItalic">Brevibacterium</span> genus and is the most frequently found in clinical samples.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Even so, infections caused by <span class="elsevierStyleItalic">B. casei</span> are rare and occur mostly in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cases of catheter sepsis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and endocarditis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> have been described in the literature, among others. In the ophthalmological field, a case of acute dacryocystitis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> was reported, which allows us to suppose that it can be found as saprophyte of the periocular tissue and of the lacrimal ducts. A case of infectious keratitis related to drug abuse has also been described.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In addition, two cases of endophthalmitis by <span class="elsevierStyleItalic">B. casei</span> have been reported, one endogenous<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the other secondary to vegetable trauma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the case of this diabetic patient, local intravitreal corticoid treatment, together with colonization in the skin and/or tear duct, could have acted as facilitators of the infection, thus causing the described devastating visual consequences.</p><p id="par0065" class="elsevierStylePara elsevierViewall">To corroborate this hypothesis, during the follow-up it was found that the patient did not exhibit symptoms or signs related to another secondary pathology, and through laboratory tests and analyses other frequent causes of acquired immunodeficiency in the adult were ruled out. On the other hand, the patient referred not having drug dependencies.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Thus, it can be said that this is the first case in which acute endophthalmitis by <span class="elsevierStyleItalic">B. casei is</span> described after an ophthalmological procedure. This allows us to confirm this species as a potential intraocular infectious agent.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Financing</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors state that there is no conflict of financial interests in this manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1583670" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1425299" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1583671" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1425298" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Financing" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-30" "fechaAceptado" => "2020-09-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1425299" "palabras" => array:5 [ 0 => "Brevibacterium" 1 => "Endophthalmitis" 2 => "Intravitreal injection" 3 => "Intravitreal implant" 4 => "Dexamethasone" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1425298" "palabras" => array:5 [ 0 => "Brevibacterium" 1 => "Endoftalmitis" 2 => "Inyección intravítrea" 3 => "Implante intravítreo" 4 => "Dexametasona" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">49-year-old man with diabetic macular edema refractory to antiangiogenics, it is decided to perform therapy with intravitreal dexamethasone implant (Ozurdex; Allergan, California, United States of America). Seven days after treatment, he showed acute endophthalmitis suggestive signs. Despite the intravitreal injection of antibiotics, the patient got worse. Vitreous sampling was repeated for Gram and cultures, and vitrectomy was performed via <span class="elsevierStyleItalic">pars</span> plana. The culture suggested the development of <span class="elsevierStyleItalic">Brevibacterium species.</span> Through an additional test, the presence of <span class="elsevierStyleItalic">Brevibacterium casei</span> was confirmed. Despite the treatment adjusted by antibiogram, retinal ischemia and macular atrophy was evident.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Brevibacterium casei</span> is a Gram-positive bacterium, barely pathogenic, that mainly affects immunodepressed patients. Only two cases of endophthalmitis are described, one endogenous and the other one secondary to vegetal trauma. This is the first case of endophthalmitis, secondary to an ophthalmological procedure.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hombre de 49 años, con edema macular diabético refractario a antiangiogénicos, en el que se realizó terapia intravítrea con implante de dexametasona (Ozurdex; Allergan, California, Estados Unidos de América). Tras siete días, presentó signos sugerentes de endoftalmitis aguda. Pese a la inyección intravítrea de antibióticos, el paciente empeoró. Se repitió la toma de muestras en vítreo para Gram y cultivos, y se realizó vitrectomía vía <span class="elsevierStyleItalic">pars</span> plana. El cultivo sugirió el desarrollo de <span class="elsevierStyleItalic">Brevibacterium species.</span> Mediante una prueba adicional, se confirmó la presencia de <span class="elsevierStyleItalic">Brevibacterium casei.</span> Pese al tratamiento ajustado por antibiograma, se evidenció isquemia retiniana y atrofia macular.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusión</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Brevibacterium casei</span> es una bacteria Gram-positiva, escasamente patógena, que afecta principalmente a inmunodeprimidos. Se han descrito solo dos casos de endoftalmitis, una endógena y otra secundaria a trauma vegetal. Este es el primer caso de endoftalmitis por <span class="elsevierStyleItalic">Brevibacterium casei</span>, secundaria a procedimiento oftalmológico.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Olate-Pérez A, Díaz-Céspedes RA, Ruíz-del-Río N, Hernández-Pérez D, Duch-Samper A. Endoftalmitis aguda por <span class="elsevierStyleItalic">Brevibacterium casei</span> tras implante intravítreo de dexametasona. Arch Soc Esp Oftalmol. 2021;96:549–551.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 690 "Ancho" => 2093 "Tamanyo" => 184779 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Images at 14 days of postoperative follow-up. a) Biomicroscopy: pigmented keratin precipitates. b) Fundoscopy: signs of retinal ischemia. c) Macular OCT: foveal atrophy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical microbiology of coryneform bacteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. 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