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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 249-250

A rare case of Staphylococcus caprae keratitis with endophthalmitis after phacoemulsification surgery


1 Department of Cornea and Refractive Surgery, Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot, Madhya Pradesh, India
2 Cornea and Refractive Services, Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot, Madhya Pradesh, India

Date of Submission13-Jul-2020
Date of Acceptance30-Oct-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Prashant Borde
Department of Cornea and Refractive Services, Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot, Madhya Pradesh - 210 204
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2240_20

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  Abstract 


Staphylococcus caprae is a catalase-positive and coagulase-negative organism that has been implicated in many systemic human infections but rarely in ocular infections. We present a rare case of S. caprae keratitis after phacoemulsification surgery. A 63-year-old male presented with the complaints of pain, redness in OS for 3 days following a phacoemulsification surgery. Cornea had an epithelial defect with a ring-shaped deep infiltrate. Temporary keratoprosthesis-associated pars plana vitrectomy was done followed by penetrating keratoplasty. Staphylococcus caprae was identified in culture. This case report points out to the pathogenic potential of S. caprae in keratitis in immunocompetent patient.

Keywords: Infective keratitis, Staphylococcus caprae, temporary keratoprosthesis, VITEK 2


How to cite this article:
Parmar G, Borde P, Meena AK, Gupta VA. A rare case of Staphylococcus caprae keratitis with endophthalmitis after phacoemulsification surgery. Indian J Ophthalmol Case Rep 2021;1:249-50

How to cite this URL:
Parmar G, Borde P, Meena AK, Gupta VA. A rare case of Staphylococcus caprae keratitis with endophthalmitis after phacoemulsification surgery. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jun 14];1:249-50. Available from: https://www.ijoreports.in/text.asp?2021/1/2/249/312366



Staphylococcus caprae is a catalase-positive and coagulase-negative bacterium which is a common skin commensal. It was first isolated in the year 1983 from goat milk, and was later found to inhabit human skin and nasal mucosa and is capable of infecting neonates, infants, and adults.[1]

Only single case reports of S. caprae associated keratitis and endophthalmitis are available, and there are no cases reported from India.[2] Here we present a first case of culture proven S. caprae keratitis with its clinical presentation, management and outcome after cataract surgery.


  Case Report Top


A 63-year-old male presented with complaints of pain and redness in OS for 3 days. Patient had undergone phacoemulsification in OS, 5 days back. Visual acuity was perception of light and accurate projection of rays. An epithelial defect of size 8 mm × 8 mm was noted with a ring-shaped deep infiltrate of outer diameter 9 mm and width of 2–3 mm [Figure 1]. Hypopyon of size 2 mm was noted. Yellow pupillary reflex was appreciated but fundus could not be visualized. B scan ultrasonography showed severe vitritis. OD was unremarkable.
Figure 1: Clinical and Microbiology images. (a). Slit lamp photo showing ring shaped deep infiltrate with vitreous exudates behind IOL. (b). Slit lamp photo at 1 month post-operatively with clear graft. (c). Colonies of Staphylococcus Caprae on blood agar. (d). Microscopy Photo of Staphylococcus Caprae on gram stain

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Corneal scraping was not possible due to deep infiltrates. Patient was diagnosed as post cataract surgery keratitis with endophthalmitis and planned for temporary kerato-prosthesis assisted pars plana vitrectomy (PPV) with therapeutic penetrating keratoplasty as there was limited view of posterior segment due to infected cornea. Fortified cefazoline 5% q2h (Reflin, Ranbaxy, India) was started in the affected eye.

Under peribulbar anesthesia, conjunctival peritomy was done and after trephining 7.5 mm of the central cornea, a Landers wide field temporary Kerato-prosthesis (K-pro) (OLTK-7.5) of size 7.5 mm was secured with 6-0 silk sutures (Ethicon, Johnson & Johnson, US). Vitreous biopsy (0.5 ml) was retrieved with a 20-gauge vitrectomy cutter. PCIOL was explanted. After removal of temporary K-pro, an excess corneal rim of 4 mm was excised by free hand dissection to include the peripheral infiltrates. Exudates were removed from the angles; thorough antibiotic wash was done and keratoplasty (TPK) was done with corneal graft size 11.5 mm and intravitreal Inj. of Vancomycin (1 mg/0.1 ml) and ceftazidime (2.2 mg/0.1 ml) was administered. Vitreous biopsy and corneal button were sent for microbiological evaluation. The tissue was cut into multiple pieces and suspended in peptone water and later inoculum was streaked on blood agar (BA), chocolate agar (CA) and sabourauds dextrose agar (SDA). Similarly, the vitreous sample was streaked over the three agars.

After incubating for 24 hours at 37°C aerobically, growth from the corneal sample was seen on blood and chocolate agar. The colonies on BA were cream colored and on microscopy showed gram-positive cocci in clusters [Figure 1]. The organism was confirmed by VITEK 2 microbiological identification system with VITEK GP card (VITEK® compact bioMérieux, Marcy l'Etoile, France) as S. caprae. On antibiotic sensitivity testing the strain was found to be sensitive to moxifloxacin and levofloxacin. There was no growth on any culture media from vitreous samples.

On postoperative day 1, patient had reduced pain while UCVA was hand movement due to fibrinous reaction in anterior chamber. Topical moxifloxacin 0.5%, q2h (Vigamox, Alcon, U.S.) was started along with prednisolone 1%, q2h, (Predforte, Allergan, Ireland.) with Timolol 0.5%, bid (Timoloast, Alcon, USA). Posterior segment had mild vitritis for which intravitreal antibiotic, Inj. Vancomycin (1 mg/0.1 ml) was repeated once on POD 3. At 1-month follow-up, the patient had BCVA of 6/60 on Snellen's chart and graft clarity 3+ with sterile suture infiltrates and a clear vitreous cavity on B scan ultrasonography [Figure 1].


  Discussion Top


Staphylococcus caprae is a normal human skin commensal implicated in hospital-acquired bone and joint infections, urinary tract infection otitis externa and endocarditis but not in corneal infections.[3] Staphylococcus caprae belongs to the “Epidermidis cluster group” which includes S. epidermidis, S. capitis and S. saccharolyticus on the basis of phylogenetic analysis.[4] These pathogens along with S. caprae are implicated in various nosocomial infections as they share similar fundamental mechanisms.[5]

Many strains of S. caprae isolated from human clinical specimens, have been misidentified as S. hominis and S. haemolyticus in conventional tests and has led to the under reporting of S. caprae associated infection in the literature.[5] Also, similar virulence factors were revealed when genome analysis of S. caprae was compared with other staphylococcal species.[6]

We identified S. caprae on VITEK 2 system which has 92.8% sensitivity for detection of S. caprae in human isolates.[7] VITEK 2 microbiological identification system is an automated machine dedicated to provide accurate phenotypic identification for most staphylococcal species with a sensitivity of 93.2% using a gram-positive (GP) identification card (bioMérieux, Marcy l'Etoile, France).[8]

The pathogen was highly sensitive to moxifloxacin, levofloxacin and ciprofloxacin while intermediately sensitive to amikacin and gatifloxacin. VITEK 2 system has been efficiently used for the antibiotic sensitivity testing of different staphylococcal species and its performance is comparable to broth microdilution method.[9]

Arias Roberta et al. reported a single case of S. caprae keratitis out of 187 patients of infective keratitis, but the details of the clinical presentation and management were not reported. In our case, S. caprae presented with a peripheral ring-shaped deep infiltrate mimicking acanthamoeba keratitis which is unique as it may lead to misdiagnosis based solely on clinical presentation.

Our patient presented with endophthalmitis along with keratitis which was not amenable to topical and systemic treatment shows the severity of the infection which can be induced by S. caprae in patients operated by cataract surgery. Early detection of such pathogen and relevant treatment is important to decrease permanent visual loss and prevent complications like descemetocele, perforation, ectatic cicatrix or dense corneal scarring.[11],[12]


  Conclusion Top


The present case report points out to the pathogenic potential of S. caprae in causing keratitis with endophthalmitis in immunocompetent patient. An early diagnosis on the basis of culture and sensitivity is necessary to prevent the grave clinical course and its complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Seng P, Barbe M, Pinelli PO, Gouriet F, Drancourt M, Minebois A, et al. Staphylococcus caprae bone and joint infections: A re-emerging infection? Clin Microbiol Infect 2014;20:O1052-8.  Back to cited text no. 1
    
2.
Henry CR, Schwartz SG, Flynn HW Jr. Endophthalmitis following pars plana vitrectomy for vitreous floaters. Clin Ophthalmol 2014;8:1649-53.  Back to cited text no. 2
    
3.
Ross TL, Fuss EP, Harrington SM, Cai M, Perl TM, Merz WG. Methicillin-resistant Staphylococcus caprae in a neonatal intensive care unit. J Clin Microbiol 2005;43:363-7.  Back to cited text no. 3
    
4.
Lamers RP, Muthukrishnan G, Castoe TA, Tafur S, Cole AM, Parkinson CL. Phylogenetic relationships among Staphylococcus species and refinement of cluster groups based on multilocus data. BMC Evol Biol 2012;12:171.  Back to cited text no. 4
    
5.
Kawamura Y, Hou XG, Sultana F, Hirose K, Miyake M, Shu SE, et al. Distribution of staphylococcus species among human clinical specimens and emended description of staphylococcus caprae. J Clin Microbiol 1998;36:2038-42.  Back to cited text no. 5
    
6.
Watanabe S, Aiba Y, Tan XE, Li FY, Boonsiri T, Thitiananpakorn K, et al. Complete genome sequencing of three human clinical isolates of Staphylococcus caprae reveals virulence factors similar to those of S. epidermidis and S. capitis. BMC Genomics 2018;19:810.  Back to cited text no. 6
    
7.
d'Ersu J, Aubin GG, Mercier P, Nicollet P, Bémer P, Corvec S. Characterization of Staphylococcus caprae clinical isolates involved in human bone and joint infections, compared with goat mastitis isolates. J Clin Microbiol 2016;54:106-13.  Back to cited text no. 7
    
8.
Delmas J, Chacornac JP, Robin F, Giammarinaro P, Talon R, Bonnet R. Evaluation of the Vitek 2 system with a variety of staphylococcus species. J Clin Microbiol 2008;46311-3.  Back to cited text no. 8
    
9.
Bobenchik AM, Hindler JA, Giltner CL, Saeki S, Humphries RM. Performance of Vitek 2 for antimicrobial susceptibility testing of Staphylococcus spp. and Enterococcus spp. J Clin Microbiol 2014;52:392-7  Back to cited text no. 9
    
10.
Farias R, Pinho L, Santos R. Epidemiological profile of infectious keratitis. Rev Bras Oftalmol 2017;76:116-20.  Back to cited text no. 10
    
11.
Mascarenhas J, Srinivasan M, Chen M, Rajaraman R, Ravindran M, Lalitha P, et al. Differentiation of etiologic agents of bacterial keratitis from presentation characteristics. Int Ophthalmol 2012;32:531-8.  Back to cited text no. 11
    
12.
Kenyon KR, Ghinelli E, Chaves HV. Morphology and pathologic response in corneal and conjunctival disease. In: Foster CS, Azar DT, Dohlman CH, editors. Smolin and Thoft's Cornea. 4th ed. NY: Lippincott Williams and Wilkins; 2005. p. 103-40.  Back to cited text no. 12
    


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