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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 39-40

A case of double hypopyon secondary to Serratia keratitis after penetrating keratoplasty


1 Department of Ophthalmology, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India
2 Department of Microbiology, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India

Date of Submission20-Jul-2021
Date of Acceptance02-Sep-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Ajit Kumar
MS Ophthalmology, CL Gupta Eye Institute, Ram Ganga Vihar, Phase 2 (Ext), Moradabad - 244 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1924_21

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  Abstract 


We report a case of a 39-year-old male who underwent therapeutic penetrating keratoplasty in his left eye. Three weeks after the procedure, he presented with complaints of blurred vision, redness in the eye, and ocular pain after trauma by insect bite four days back. Slit-lamp examination revealed central epithelial defect with deep stromal infiltrate accompanied by a double hypopyon. Serratia sp. was isolated on cultures. Serratia marcescens was confirmed on the VITEK 2 system. Isolated organism was sensitive to imipenem. Fortified imipenem 1% eye drop was started on a half-hourly basis. At six weeks follow-up, resolving infiltrate with significant corneal scarring and vascularization was seen.

Keywords: Infectious keratitis, post-penetrating keratoplasty, Serratia marcescens


How to cite this article:
Kumar A, Khurana A, Sharma M. A case of double hypopyon secondary to Serratia keratitis after penetrating keratoplasty. Indian J Ophthalmol Case Rep 2022;2:39-40

How to cite this URL:
Kumar A, Khurana A, Sharma M. A case of double hypopyon secondary to Serratia keratitis after penetrating keratoplasty. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:39-40. Available from: https://www.ijoreports.in/text.asp?2022/2/1/39/334920



Serratia species are opportunistic Gram-negative bacteria that belong to the large family of Enterobacteriaceae, with Serratia marcescens being the primary pathogenic species.[1] S. marcescens is a gram-negative coccobacillus.[2] Risk for Serratia keratitis is associated with abnormal corneal surface, topical medication use, and contact lens wear.[1],[3] It can also cause refractory keratitis, resulting in corneal perforation and blindness. Ocular infections are often associated with contact lens wear, use of contaminated topical medications, and previous ocular surgery. The clinical presentation is characterized by diffuse haziness of the corneal epithelium and central or peripheral infiltrates with hypopyon.[4] We hereby describe a unique hitherto unreported clinical picture of bacterial keratitis after penetrating keratoplasty caused by Serratia spp.


  Case Report Top


A 39-year-old male presented to our cornea clinic, complaining of blurred vision, redness, and pain in his left eye for 4 days. He described a prior history of therapeutic penetrating keratoplasty done elsewhere for nonresolving fungal keratitis three months prior to his presentation. On examination, he was found to have normal vital signs. His best-corrected visual acuities were 20/20 in the right eye and perception of hand movements close to the face in the left eye. Slit-lamp examination revealed normal lid margins and conjunctival congestion and an edematous 8-mm corneal graft with a Descemet's membrane detachment that probably gave rise to the overlying corneal edema and compromised ocular surface. There was a central epithelial defect (2.7 × 2.3 mm) with deep stromal infiltrate accompanied by double hypopyon [Figure 1], one posterior to the stroma (1.5 mm in height and pink in color) and the other posterior to a large detached Descemet's membrane (whitish in color and 3 mm in height), which was limited by posterior adhesions to iris surface approximately 2.5 mm from limbus nasally inferiorly and temporally. The graft host junction was well apposed with 16 intact sutures. The rest of the exam was unremarkable. B-scan ultrasonography was within normal limits.
Figure 1: (a) (Day 0) Graft host junction well apposed with 16 intact sutures, epithelial defect (2.5 × 2.3) with stromal infiltrates, microcystic edema inferiorly, and double hypopyon. (b) (Day 3) Graft host junction well apposed with 16 intact sutures, epithelial defect (2.7 × 2.3) with infiltrates, microcystic edema inferiorly, and hypopyon. (c) (Day 6) Corneal graft in place with healing epithelial defect and resolving infiltrates. (d) (Day 14) Corneal graft in place with healed epithelial defect and infiltrates with stromal edema

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Corneal scrapings were obtained from the base and active edge of the ulcer using a sterile surgical blade (#15 on a Bard– Parker handle) under topical anesthesia (0.5% proparacaine hydrochloride) under slit-lamp magnification. Gram stain and 10% potassium hydroxide mount were included as a part of the standard protocol for microscopic evaluation of corneal smears. Gram-stained smears were examined at ×400 and ×1000 magnification, and the potassium hydroxide preparations were examined at ×200 and ×400 magnification under light microscope. Scrapings for smears were collected prior to those for culture. Gram-negative coccobacilli were identified on Gram stain. Fortified cefazolin (5%) with ciprofloxacin (0.3%) was started as a standard empirical therapy on a half-hourly basis.

The culture was inoculated on sheep blood agar, chocolate agar, brain heart infusion broth, Sabouraud dextrose agar, and thioglycolate media. The samples were inoculated directly onto the solid culture media by making a row of “C” streak marks. For inoculation into the liquid media, the blades were swirled directly in the culture fluid. Serratia spp. was isolated on blood agar, nutrient agar, brain heart infusion, and thioglycolate media [Figure 2]. S. marcescens was confirmed on the VITEK 2 system [Figure 3]. Isolated S. marcescens were sensitive to imipenem. Based on the antibiotic sensitivity report, fortified imipenem (1%) eye drop was started on a half-hourly basis. The patient was followed up on day 3 and day 7 [Figure 1]. The pink color of the anterior hypopyon slowly faded away to whitish color after 7 days of therapy. The antibiotic intensive therapy was reduced to 6 times a day after the infiltrates began to resolve and the epithelial defect started healing. The patient responded well to the treatment. Six weeks after presentation, slit-lamp examination revealed resolved infiltrate with significant corneal scarring and vascularization [Figure 1]. His BCVA of the left eye at the last follow-up was counting finger at 1 m.
Figure 2: Serratia spp. identified on culture

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Figure 3: Serratia marcescens confirmed on VITEK 2 system

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  Discussion Top


Serratia marcescens keratitis is associated with poor ocular surface and contact lens-related infections[5],[6],[7] and also causes other infections such as purulent conjunctivitis, scleritis, and endophthalmitis. Mah-Sadorra et al. reported abnormal corneal surface in those who had undergone PK as a predisposing factor associated with Serratia corneal ulcers.[3] Our patient also had a history of therapeutic PK done elsewhere. Serratia spp. have been widely reported to cause a pink hypopyon, previously described as an important clinical feature of corneal ulceration caused by S. marcescens.[6] This was attributed to a red pigment prodigiosin produced by the bacteria, which adds the distinct pink color that can alert the treating physician to the possibility of Enterobacteriaceae, either Klabesiella or Serratia, as the causative agent. Mah-Sadorra et al. reported hypopyon only in one patient out of 21 cases of Serratia corneal ulcers reported.[3] S. marcescens is known to be a multidrug-resistant pathogen.

The presence of a double hypopyon can be attributed to the intense nature of inflammation, which could have given rise to a deep corneal abscess in the graft and producing a reactionary hypopyon in the anterior chamber, which presented as the larger deeper hypopyon. The second, more superficial pink hypopyon noticed at the deeper layer of the graft can be attributed to the continuation of the infection and then subsequent rupture of the abscess into the potential space caused by the detached Descemet's membrane of the grafted cornea. A case of double hypopyon has been reported in Pseudomonas keratitis.[8] We report the first case of double hypopyon in Serratia keratitis after penetrating keratitis.


  Conclusion Top


Serratia marcescens keratitis can present with a unique clinical picture of a double hypopyon. Medical therapy with fortified imipenem resulted in a good clinical response in our case.

Acknowledgement

The authors would like to thank Mr. Lokesh Chauhan, Department of clinical research, CL Gupta Eye Institute, Moradabad (India) for his technical assistance in preparing this manuscript.

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.
Hejazi A, Falkiner FR. Serratia marcescens. J Med Microbiol 1997;46:903-12.  Back to cited text no. 1
    
2.
Equi RA, Green WR. Endogenous Serratia marcescens endophthalmitis with dark hypopyon: A case report and review. Surv Ophthalmol 2001;46:259-68.  Back to cited text no. 2
    
3.
Mah-Sadorra JH, Najjar DM, Rapuano CJ, Laibson PR, Cohen EJ. Serratia corneal ulcers: A retrospective clinical study. Cornea 2005;24:793-800.  Back to cited text no. 3
    
4.
Parment PA. The role of Serratia marcescens in soft contact lens associated ocular infection. Acta Ophthalmol Scand 1997;75:67-71.  Back to cited text no. 4
    
5.
Pinna A, Usai D, Sechi LA, Carta A, Zanetti S. Detection of virulence factors in Serratia strains isolated from contact lens associated corneal ulcers. Acta Ophthalmol 2011:89:382-7.  Back to cited text no. 5
    
6.
Stefater JA, Borkar DS, Chodosh J. Pink hypopyon in a patient with Serratia marcescens corneal ulceration. J Ophthalmic Inflamm Infect 2015;5:9. doi: 10.1186/s12348-015-0041-4.  Back to cited text no. 6
    
7.
Bharathi MJ, Ramakrishnan R, Meenakshi R, Kumar CS, Padmavathy S, Mittal S. Ulcerative keratitis associated with contact lens wear. Indian J Ophthalmol 2007;55:64-7.  Back to cited text no. 7
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8.
Osborne SA, Al Ahmar B, Gerges S. A case of 'double hypopyon' secondary to Pseudomonas aeruginosa keratitis in a patient with longstanding rubeotic glaucoma. Acta Ophthalmol Scand 2005;83:510-1.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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