Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum

Nandini Venkateswaran,1 Gabrielle Yeaney,2 Mina Chung,3,4 Holly B Hindman3,41University of Rochester School of Medicine and Dentistry, University of Rochester, 2Department of Pathology and Laboratory Medicine, 3Flaum Eye Institute, 4Center for Visual Science, University of Rochester School...

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Autores principales:	Venkateswaran N, Yeaney G, Chung M, Hindman HB
Formato:	article
Lenguaje:	EN
Publicado:	Dove Medical Press 2014
Materias:	Ophthalmology RE1-994
Acceso en línea:	https://doaj.org/article/51301d0bdea24462a27bc5decf2c10bb
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spelling	oai:doaj.org-article:51301d0bdea24462a27bc5decf2c10bb2021-12-02T00:56:26ZRecurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum1177-5483https://doaj.org/article/51301d0bdea24462a27bc5decf2c10bb2014-05-01T00:00:00Zhttp://www.dovepress.com/recurrent-nontuberculous-mycobacterial-endophthalmitis-a-diagnostic-co-a16622https://doaj.org/toc/1177-5483 Nandini Venkateswaran,1 Gabrielle Yeaney,2 Mina Chung,3,4 Holly B Hindman3,41University of Rochester School of Medicine and Dentistry, University of Rochester, 2Department of Pathology and Laboratory Medicine, 3Flaum Eye Institute, 4Center for Visual Science, University of Rochester School of Medicine and Dentistry, Rochester, NY, USAObjective: To report a case of recurrent nontuberculous mycobacterial endophthalmitis in the context of neurotrophic keratopathy secondary to herpes zoster ophthalmicus that had an atypical presentation and complex course, and highlights the challenges of causative organism identification and therapeutic interventions in this condition.Methods: A retrospective chart review was conducted to determine the visual outcomes of the patient.Results: A 68-year-old pseudophakic male with long-standing neurotrophic keratopathy and perforated descemetocele managed with cyanoacrylate glue and a contact bandage lens in the left eye, began experiencing recurrent episodes of endophthalmitis after undergoing a penetrating keratoplasty. Several therapeutic procedures including an anterior chamber washout, two pars plana vitrectomies, explantation of the posterior chamber intraocular lens and capsular bag, and multiple intravitreal antimicrobial injections, were performed to which he has ultimately responded favorably, with no signs of infection to date and stable visual acuity. The causative organism of his recurrent infections was initially identified as Mycobacterium abscessus through biochemical testing and 16S ribosomal ribonucleic acid gene sequencing; however, repeat polymerase chain reaction (PCR) and sequencing of the 65 kDa heat shock protein (hsp65) gene for experimental purposes confirmed the accurate identification of the organism to be Mycobacterium chelonae. Given the greater reliability of PCR and sequencing of the hsp65 gene over traditional biochemical tests and culture techniques, M. chelonae was likely the infectious agent all along, and the organism was originally misidentified on the basis of less accurate tests.Conclusion: Recurrent atypical mycobacterial endophthalmitis requires expedient identification and management to prevent poor visual outcomes. Standard biochemical testing can identify the causative organism but is limited by the inability to distinguish between nontuberculous species reliably. We recommend the use of PCR in conjunction with sequencing of the hsp65 gene for reliable differentiation of M. chelonae and M. abscessus in atypical mycobacterial ocular infections. Minimum inhibitory concentration antibiotic susceptibility tests on cultured strains are the best guide to antibiotic selection, given the rapidly rising resistance to antimicrobials in atypical mycobacterial species.Keywords: atypical mycobacteria, herpes zoster ophthalmicus, hsp65, Mycobacterium chelonae, neurotrophic keratopathy, visual outcomeVenkateswaran NYeaney GChung MHindman HBDove Medical PressarticleOphthalmologyRE1-994ENClinical Ophthalmology, Vol 2014, Iss default, Pp 837-842 (2014)
institution	DOAJ
collection	DOAJ
language	EN
topic	Ophthalmology RE1-994
spellingShingle	Ophthalmology RE1-994 Venkateswaran N Yeaney G Chung M Hindman HB Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
description	Nandini Venkateswaran,1 Gabrielle Yeaney,2 Mina Chung,3,4 Holly B Hindman3,41University of Rochester School of Medicine and Dentistry, University of Rochester, 2Department of Pathology and Laboratory Medicine, 3Flaum Eye Institute, 4Center for Visual Science, University of Rochester School of Medicine and Dentistry, Rochester, NY, USAObjective: To report a case of recurrent nontuberculous mycobacterial endophthalmitis in the context of neurotrophic keratopathy secondary to herpes zoster ophthalmicus that had an atypical presentation and complex course, and highlights the challenges of causative organism identification and therapeutic interventions in this condition.Methods: A retrospective chart review was conducted to determine the visual outcomes of the patient.Results: A 68-year-old pseudophakic male with long-standing neurotrophic keratopathy and perforated descemetocele managed with cyanoacrylate glue and a contact bandage lens in the left eye, began experiencing recurrent episodes of endophthalmitis after undergoing a penetrating keratoplasty. Several therapeutic procedures including an anterior chamber washout, two pars plana vitrectomies, explantation of the posterior chamber intraocular lens and capsular bag, and multiple intravitreal antimicrobial injections, were performed to which he has ultimately responded favorably, with no signs of infection to date and stable visual acuity. The causative organism of his recurrent infections was initially identified as Mycobacterium abscessus through biochemical testing and 16S ribosomal ribonucleic acid gene sequencing; however, repeat polymerase chain reaction (PCR) and sequencing of the 65 kDa heat shock protein (hsp65) gene for experimental purposes confirmed the accurate identification of the organism to be Mycobacterium chelonae. Given the greater reliability of PCR and sequencing of the hsp65 gene over traditional biochemical tests and culture techniques, M. chelonae was likely the infectious agent all along, and the organism was originally misidentified on the basis of less accurate tests.Conclusion: Recurrent atypical mycobacterial endophthalmitis requires expedient identification and management to prevent poor visual outcomes. Standard biochemical testing can identify the causative organism but is limited by the inability to distinguish between nontuberculous species reliably. We recommend the use of PCR in conjunction with sequencing of the hsp65 gene for reliable differentiation of M. chelonae and M. abscessus in atypical mycobacterial ocular infections. Minimum inhibitory concentration antibiotic susceptibility tests on cultured strains are the best guide to antibiotic selection, given the rapidly rising resistance to antimicrobials in atypical mycobacterial species.Keywords: atypical mycobacteria, herpes zoster ophthalmicus, hsp65, Mycobacterium chelonae, neurotrophic keratopathy, visual outcome
format	article
author	Venkateswaran N Yeaney G Chung M Hindman HB
author_facet	Venkateswaran N Yeaney G Chung M Hindman HB
author_sort	Venkateswaran N
title	Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
title_short	Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
title_full	Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
title_fullStr	Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
title_full_unstemmed	Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
title_sort	recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum
publisher	Dove Medical Press
publishDate	2014
url	https://doaj.org/article/51301d0bdea24462a27bc5decf2c10bb
work_keys_str_mv	AT venkateswarann recurrentnontuberculousmycobacterialendophthalmitisadiagnosticconundrum AT yeaneyg recurrentnontuberculousmycobacterialendophthalmitisadiagnosticconundrum AT chungm recurrentnontuberculousmycobacterialendophthalmitisadiagnosticconundrum AT hindmanhb recurrentnontuberculousmycobacterialendophthalmitisadiagnosticconundrum
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Recurrent nontuberculous mycobacterial endophthalmitis: a diagnostic conundrum

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