Bacillus Emilio
cereus
Endogenous Panophthalmitis
Bouza, MD; Scott Grant, MD; M. Colin Jordan, MD; Richard H. Yook, MD; Hector L. Sulit, MD
suppurative endoge¬ panophthalmitis caused by Bacillus cereus resulted from intravenously ad¬ ministered medications. This is the first, •
A
case
of
severe
nous
to our knowledge, well-documented case of endogenous endophthalmitis asso¬ ciated with this organism. It is recom¬ mended that If on Gram's stain of the anterior chamber fluid, Gram-positive rods are seen, chloramphenicol should be administered in addition to penicillin because of the possibility of cereus infection.
(Arch Ophthalmol 97:498-499, 1979)
"Dacterial panophthalmitis following
ocular surgery or trauma to the eye is well known.1 Less frequently, such infections result from bacteremia. In this report we describe a patient with bacterial panophthalmi¬ tis caused by an organism that is usually considered a noninvasive sap¬ rophyte. In this instance, the iatro¬ genic nature of the infection was clearly documented. REPORT OF A CASE A
43-year-old, previously healthy
man
referred to the Jules Stein Eye Insti¬ tute with a 12-hour history of pain, swell¬ ing, and severe loss of vision in the right eye. For several weeks prior to the onset of illness, the patient received twice weekly intravenous (IV) injections of cyanocobalamin, gluconate calcium, and other vita¬ mins by his private physician. The last injection was administered less than 24 hours prior to the onset of the patient's initial symptoms. There was no history of was
eye trauma.
On admission, physical examination showed a temperature of 39 °C (102 °F), a pulse rate of 86 beats per minute, a blood pressure of 140/80 mm Hg, and mild lethargy. Visual acuity was limited to light
Accepted
for publication June 9, 1978. From the Division of Infectious Diseases, Department of Medicine (Drs Bouza and Jordan), and the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles (Drs Grant, Yook, and Sulit). Reprint requests to Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA 90024
(Dr Grant).
in the right eye and 6/6 in the left eye. The right eye (Fig 1) exhibited marked congestion of the bulbar and palpe¬ brai conjunctivae and a hazy edematous cornea with a ring infiltrate. The eyelids were swollen and the extraocular move¬ ments were severely restricted in all direc¬ tions of gaze. The anterior chamber was poorly visualized. The fundus could not be seen in the right eye; in the left eye, it was within normal limits. Findings from the remainder of the physical examination were unremarkable. Laboratory studies disclosed a WBC count of 11,400/µ1, with 89% neutrophils, 10% lymphocytes, and 1% monocytes. Hemoglobin, hematocrit, and serum elec¬ trolyte values, findings from routine urinalysis and liver function tests, and chest and orbital roentgenograms were within normal limits. Computerized axial tomo¬ graphy of the brain and orbit failed to show any abnormalities other than slight proptosis of the right eye. Shortly after admission, an anterior chamber paracentesis was performed. Gram's stain of the fluid revealed a few polymorphonuclear leukocytes with large Gram-positive rods inside and outside the WBCs (Fig 2). A vitreous tap was not performed because of poor visualization of ocular landmarks. Cultures of the anterior chamber fluid subsequently showed a pure growth of Bacillus cereus within 24 hours, while cultures from the right conjunctivae grew Staphylococcus epidermidis. Two blood cultures taken on admission were sterile and a urine culture showed greater than 10s colonies of a Bacillus species that was not identified further. Treatment was instituted intravenously with chloramphenicol (3 g/day) and gen¬ tamicin sulfate (4.5 mg/kg/day). In addi¬ tion, a single 20-mg dose of gentamicin sulfate was administered by sub-Tenon's capsule injection at the time of paracente¬ sis. However, because of irreversible loss of ocular function and continuing infection and pain, the right eye was enucleated on the third hospital day. During the surgical procedure, the globe was found to be ruptured at the superonasal area about the equator; it communicated with an abscess cavity that contained approximately 4 ml of brownish purulent material that subse¬ quently grew cereus. The chlorampheni¬ col therapy was continued postoperatively, but the gentamicin therapy was stopped. The patient recovered uneventfully after a total of ten days of antibiotic treatment.
perception
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/03/2015
MICROBIOLOGICAL AND EPIDEMIOLOGIC STUDIES
Three multidose vitamin and miner¬ al vials from which the patient had received his IV injections by his private physician were obtained for investigation. Bacillus cereus was isolated from all three vials in pure culture. Results of antibiotic suscepti¬ bility tests in broth using cereus from the vials and from the patient's eye were identical. The organisms
susceptible to chloramphenicol, erythromycin, gentamicin, and ami¬ kacin and resistant to penicillins and cephalosporins. were
PATHOLOGICAL FINDINGS
Examination of the enucleated eye showed greatly disorganized ocular contents. The cornea, anterior cham¬
ber, iris, ciliary body, vitreous, sclera, and optic nerve were all infiltrated with polymorphonuclear leukocytes. The retina was represented by a small detached disorganized fragment. The choroid was replaced with a large circumferential band of hemorrhage. Tissue Gram's stain showed large Gram-positive rods. This picture was consistent with a severe suppurative panophthalmitis. COMMENT
Most cases of bacterial panophthal¬ mitis result from either trauma or surgery. Although the incidence is very low, loss of the eye, or at least useful vision, frequently results.1"3 The organisms most frequently re¬ sponsible are Gram-positive cocci (es¬ pecially coagulase-positive and coagulase-negative staphylococci), followed by a variety of Gram-negative rods, including Pseudomonas aeruginosa, Proteus sp, and Escherichia coli.1'3
Endogenous panophthalmitis re¬ sulting from bacteremia and seeding of the eye is even less common and usually is associated with infection of soft tissue, abdominal abscesses, puer¬ peral fever, meningitis, or endocardi¬ tis.4"7 The causative organisms have been Sta aureus, Pr mirabilis, Ps
Fig 1—Right
eye
on
morning
Fig 2.—Gram's stain of anterior chamber fluid showing Grampositive rods, a few of which are within polymorphonuclear leukocytes (original magnification 1,000).
after admission.
aeruginosa, Neisseria meningitidis, E coli, Streptococcus pneumoniae, and others. Prior to this report, only one instance, to our knowledge, of endoge¬ nous panophthalmitis owing to a
member of the genus Bacillus had been described." Organisms of the genus are large, spore-forming, aero¬ bic, Gram-positive rods. With the exception of the etiologic agent of anthrax, anthracis, Bacillus species have been generally regarded for many years as saprophytes." More recently, however, the role of Bacillus as a pathogen in such illnesses as bacteremia, endocarditis, infection of ventriculoatrial shunts, pneumonia, meningitis, and food poisoning has been clearly documented.1"14 In ocular pathology, the "Bacillus group" has been associated with dacryocystitis, conjunctivitis, kerati¬ tis, iridocyclitis, and panophthalmi¬ tis.111" Francois14 in 1934 reviewed the ocular pathology associated with this
organism. He collected 41 case reports of traumatic panophthalmitis and stressed the very brief incubation period and the destructive nature of the disease. More recently, Davenport and Smith1" noted that many subtil¬ is organisms associated with ocular infection are actually cereus. The only reported instance of cereus
endogenous panophthalmitis
described by Kerkenezov" in 1953; the infection presumably followed a contaminated blood transfusion, al¬ though the unit of blood was not cultured. In our patient, cereus bacteremia and subsequent seeding of the eye almost certainly resulted from direct IV inoculation of bacteria, since the same organism was isolated from all of the medication vials used for the injections. In addition, the antibiotic susceptibility patterns of the orga¬ nisms isolated from the eye and from these vials were identical. As noted by was
Coonrod et al,2" cereus is uniformly resistant to penicillins, which is an important characteristic that differ¬ entiates this organism from anthracis. The central role of anterior cham¬ ber paracentesis in definitive bactéri¬ ologie documentation in panophthal¬ mitis is clearly illustrated by this case since conjunctival cultures grew only Sta epidermidis. Forster3 has shown that patients with positive anterior chamber fluid culture are more likely to suffer permanent loss of vision than those with negative cultures. When Gram-positive rods are seen on Gram's stain of anterior chamber fluid, treatment should be initiated, pending specific bactériologie identifi¬ cation, with both penicillin and chlor¬ amphenicol, since cereus and clostridia are the most likely pathogens. Nonproprietary Name and Trademark of Drug Gentamicin
sulfate—Garamycin.
References 1. Abel R, Binder PS, Bellows R: Postoperative bacterial endophthalmitis: Section 1. Ann Oph¬ thalmol 8:731, 1976. 2. Leopold IH: Doyne memorial lecture: Man¬ agement of intraocular infection. Trans Ophthal¬ mol Soc UK 91:577-610, 1971. 3. Forster RK: Endophthalmitis: Diagnostic cultures and visual results. Arch Ophthalmol
92:387-392, 1974.
4. Allansmith MR, Skaggs C, Kimura SJ: Anterior chamber paracentesis: Diagnostic value in postoperative endophthalmitis. Arch Ophthal¬ mol 84:745-748, 1970. 5. Crabb AM, Fielding IL, Ormsby HL: Bacil¬ lus proteus endophthalmitis. Am J Ophthalmol 43:86-89, 1957. 6. Peyman GA, Herbst R: Bacterial endoph¬ thalmitis: Treatment with intraocular injection of gentamicin and dexamethasone. Arch Oph¬ thalmol 91:416-418, 1974. 7. Johnson AH: Metastatic septic endophthal-
mitis. South Med J 6:879-880, 1969. 8. Kerkenezov N: Panophthalmitis after a blood transfusion: Responsible organism Bacil¬ lus cereus. Br J Ophthalmol 37:632-636, 1953. 9. Swartz MN: Aerobic spore-forming bacilli, in Davis BD, Dulbecco R, Eisen , et al (eds): Microbiology. New York, Harper & Row Publish¬
Ine, 1973, pp 819-841. 10. Farrar WE: Serious infections due to "nonpathogenic" organisms of the genus Bacilltis. Am J Med 34:134-141, 1963. 11. Ihde DC, Armstrong D: Clinical spectrum of infection due to Bacillus species. Am J Med 55:839-845, 1973. 12. Pennington JE, Gibbons ND, Strobeck JE, et al: Bacillus species infection in patients with hématologie neoplasia. JAMA 235:1473-1474, 1976. 13. Goepfert JM, Spira WM, Kim HY: Bacillus cereus: Food poisoning organism: A review. J Milk Food Technol 35:213-227, 1972.
ers
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/03/2015
14. Francois JM: Le Bacille
thologie oculaire.
subtilique en pa¬ Optalmol
Bull Mem Soc Fr
47:423, 1934.
15. Pearson HE: Human infections caused by organisms of the Bacillus species. Am J Clin Pathol 53:506-515, 1970. 16. Van Bijsterveld OP, Richards RD: Bacillus infections of the cornea. Arch Ophthalmol 74:9195, 1965. 17. Greenspon EA: A pathogenic Bacillus
subtilis isolated from the eye. Am J Ophthalmol 1:316-318, 1918. 18. Reese AB, Khorazo D: Endophthalmitis due to subtilis following injury. Am J Ophthal¬ mol 26:1251-1253, 1943. 19. Davenport R, Smith C: Panophthalmitis due to an organism of the Bacillus subtilis group. Br J Ophthalmol 36:389-392, 1952. 20. Coonrod JD, Leadley PJ, Eickhoff TC: Antibiotic susceptibility of Bacillus species. J Infect Dis 123:102-105, 1971.
cereus
Endogenous Panophthalmitis
Bouza, MD; Scott Grant, MD; M. Colin Jordan, MD; Richard H. Yook, MD; Hector L. Sulit, MD
suppurative endoge¬ panophthalmitis caused by Bacillus cereus resulted from intravenously ad¬ ministered medications. This is the first, •
A
case
of
severe
nous
to our knowledge, well-documented case of endogenous endophthalmitis asso¬ ciated with this organism. It is recom¬ mended that If on Gram's stain of the anterior chamber fluid, Gram-positive rods are seen, chloramphenicol should be administered in addition to penicillin because of the possibility of cereus infection.
(Arch Ophthalmol 97:498-499, 1979)
"Dacterial panophthalmitis following
ocular surgery or trauma to the eye is well known.1 Less frequently, such infections result from bacteremia. In this report we describe a patient with bacterial panophthalmi¬ tis caused by an organism that is usually considered a noninvasive sap¬ rophyte. In this instance, the iatro¬ genic nature of the infection was clearly documented. REPORT OF A CASE A
43-year-old, previously healthy
man
referred to the Jules Stein Eye Insti¬ tute with a 12-hour history of pain, swell¬ ing, and severe loss of vision in the right eye. For several weeks prior to the onset of illness, the patient received twice weekly intravenous (IV) injections of cyanocobalamin, gluconate calcium, and other vita¬ mins by his private physician. The last injection was administered less than 24 hours prior to the onset of the patient's initial symptoms. There was no history of was
eye trauma.
On admission, physical examination showed a temperature of 39 °C (102 °F), a pulse rate of 86 beats per minute, a blood pressure of 140/80 mm Hg, and mild lethargy. Visual acuity was limited to light
Accepted
for publication June 9, 1978. From the Division of Infectious Diseases, Department of Medicine (Drs Bouza and Jordan), and the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles (Drs Grant, Yook, and Sulit). Reprint requests to Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA 90024
(Dr Grant).
in the right eye and 6/6 in the left eye. The right eye (Fig 1) exhibited marked congestion of the bulbar and palpe¬ brai conjunctivae and a hazy edematous cornea with a ring infiltrate. The eyelids were swollen and the extraocular move¬ ments were severely restricted in all direc¬ tions of gaze. The anterior chamber was poorly visualized. The fundus could not be seen in the right eye; in the left eye, it was within normal limits. Findings from the remainder of the physical examination were unremarkable. Laboratory studies disclosed a WBC count of 11,400/µ1, with 89% neutrophils, 10% lymphocytes, and 1% monocytes. Hemoglobin, hematocrit, and serum elec¬ trolyte values, findings from routine urinalysis and liver function tests, and chest and orbital roentgenograms were within normal limits. Computerized axial tomo¬ graphy of the brain and orbit failed to show any abnormalities other than slight proptosis of the right eye. Shortly after admission, an anterior chamber paracentesis was performed. Gram's stain of the fluid revealed a few polymorphonuclear leukocytes with large Gram-positive rods inside and outside the WBCs (Fig 2). A vitreous tap was not performed because of poor visualization of ocular landmarks. Cultures of the anterior chamber fluid subsequently showed a pure growth of Bacillus cereus within 24 hours, while cultures from the right conjunctivae grew Staphylococcus epidermidis. Two blood cultures taken on admission were sterile and a urine culture showed greater than 10s colonies of a Bacillus species that was not identified further. Treatment was instituted intravenously with chloramphenicol (3 g/day) and gen¬ tamicin sulfate (4.5 mg/kg/day). In addi¬ tion, a single 20-mg dose of gentamicin sulfate was administered by sub-Tenon's capsule injection at the time of paracente¬ sis. However, because of irreversible loss of ocular function and continuing infection and pain, the right eye was enucleated on the third hospital day. During the surgical procedure, the globe was found to be ruptured at the superonasal area about the equator; it communicated with an abscess cavity that contained approximately 4 ml of brownish purulent material that subse¬ quently grew cereus. The chlorampheni¬ col therapy was continued postoperatively, but the gentamicin therapy was stopped. The patient recovered uneventfully after a total of ten days of antibiotic treatment.
perception
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/03/2015
MICROBIOLOGICAL AND EPIDEMIOLOGIC STUDIES
Three multidose vitamin and miner¬ al vials from which the patient had received his IV injections by his private physician were obtained for investigation. Bacillus cereus was isolated from all three vials in pure culture. Results of antibiotic suscepti¬ bility tests in broth using cereus from the vials and from the patient's eye were identical. The organisms
susceptible to chloramphenicol, erythromycin, gentamicin, and ami¬ kacin and resistant to penicillins and cephalosporins. were
PATHOLOGICAL FINDINGS
Examination of the enucleated eye showed greatly disorganized ocular contents. The cornea, anterior cham¬
ber, iris, ciliary body, vitreous, sclera, and optic nerve were all infiltrated with polymorphonuclear leukocytes. The retina was represented by a small detached disorganized fragment. The choroid was replaced with a large circumferential band of hemorrhage. Tissue Gram's stain showed large Gram-positive rods. This picture was consistent with a severe suppurative panophthalmitis. COMMENT
Most cases of bacterial panophthal¬ mitis result from either trauma or surgery. Although the incidence is very low, loss of the eye, or at least useful vision, frequently results.1"3 The organisms most frequently re¬ sponsible are Gram-positive cocci (es¬ pecially coagulase-positive and coagulase-negative staphylococci), followed by a variety of Gram-negative rods, including Pseudomonas aeruginosa, Proteus sp, and Escherichia coli.1'3
Endogenous panophthalmitis re¬ sulting from bacteremia and seeding of the eye is even less common and usually is associated with infection of soft tissue, abdominal abscesses, puer¬ peral fever, meningitis, or endocardi¬ tis.4"7 The causative organisms have been Sta aureus, Pr mirabilis, Ps
Fig 1—Right
eye
on
morning
Fig 2.—Gram's stain of anterior chamber fluid showing Grampositive rods, a few of which are within polymorphonuclear leukocytes (original magnification 1,000).
after admission.
aeruginosa, Neisseria meningitidis, E coli, Streptococcus pneumoniae, and others. Prior to this report, only one instance, to our knowledge, of endoge¬ nous panophthalmitis owing to a
member of the genus Bacillus had been described." Organisms of the genus are large, spore-forming, aero¬ bic, Gram-positive rods. With the exception of the etiologic agent of anthrax, anthracis, Bacillus species have been generally regarded for many years as saprophytes." More recently, however, the role of Bacillus as a pathogen in such illnesses as bacteremia, endocarditis, infection of ventriculoatrial shunts, pneumonia, meningitis, and food poisoning has been clearly documented.1"14 In ocular pathology, the "Bacillus group" has been associated with dacryocystitis, conjunctivitis, kerati¬ tis, iridocyclitis, and panophthalmi¬ tis.111" Francois14 in 1934 reviewed the ocular pathology associated with this
organism. He collected 41 case reports of traumatic panophthalmitis and stressed the very brief incubation period and the destructive nature of the disease. More recently, Davenport and Smith1" noted that many subtil¬ is organisms associated with ocular infection are actually cereus. The only reported instance of cereus
endogenous panophthalmitis
described by Kerkenezov" in 1953; the infection presumably followed a contaminated blood transfusion, al¬ though the unit of blood was not cultured. In our patient, cereus bacteremia and subsequent seeding of the eye almost certainly resulted from direct IV inoculation of bacteria, since the same organism was isolated from all of the medication vials used for the injections. In addition, the antibiotic susceptibility patterns of the orga¬ nisms isolated from the eye and from these vials were identical. As noted by was
Coonrod et al,2" cereus is uniformly resistant to penicillins, which is an important characteristic that differ¬ entiates this organism from anthracis. The central role of anterior cham¬ ber paracentesis in definitive bactéri¬ ologie documentation in panophthal¬ mitis is clearly illustrated by this case since conjunctival cultures grew only Sta epidermidis. Forster3 has shown that patients with positive anterior chamber fluid culture are more likely to suffer permanent loss of vision than those with negative cultures. When Gram-positive rods are seen on Gram's stain of anterior chamber fluid, treatment should be initiated, pending specific bactériologie identifi¬ cation, with both penicillin and chlor¬ amphenicol, since cereus and clostridia are the most likely pathogens. Nonproprietary Name and Trademark of Drug Gentamicin
sulfate—Garamycin.
References 1. Abel R, Binder PS, Bellows R: Postoperative bacterial endophthalmitis: Section 1. Ann Oph¬ thalmol 8:731, 1976. 2. Leopold IH: Doyne memorial lecture: Man¬ agement of intraocular infection. Trans Ophthal¬ mol Soc UK 91:577-610, 1971. 3. Forster RK: Endophthalmitis: Diagnostic cultures and visual results. Arch Ophthalmol
92:387-392, 1974.
4. Allansmith MR, Skaggs C, Kimura SJ: Anterior chamber paracentesis: Diagnostic value in postoperative endophthalmitis. Arch Ophthal¬ mol 84:745-748, 1970. 5. Crabb AM, Fielding IL, Ormsby HL: Bacil¬ lus proteus endophthalmitis. Am J Ophthalmol 43:86-89, 1957. 6. Peyman GA, Herbst R: Bacterial endoph¬ thalmitis: Treatment with intraocular injection of gentamicin and dexamethasone. Arch Oph¬ thalmol 91:416-418, 1974. 7. Johnson AH: Metastatic septic endophthal-
mitis. South Med J 6:879-880, 1969. 8. Kerkenezov N: Panophthalmitis after a blood transfusion: Responsible organism Bacil¬ lus cereus. Br J Ophthalmol 37:632-636, 1953. 9. Swartz MN: Aerobic spore-forming bacilli, in Davis BD, Dulbecco R, Eisen , et al (eds): Microbiology. New York, Harper & Row Publish¬
Ine, 1973, pp 819-841. 10. Farrar WE: Serious infections due to "nonpathogenic" organisms of the genus Bacilltis. Am J Med 34:134-141, 1963. 11. Ihde DC, Armstrong D: Clinical spectrum of infection due to Bacillus species. Am J Med 55:839-845, 1973. 12. Pennington JE, Gibbons ND, Strobeck JE, et al: Bacillus species infection in patients with hématologie neoplasia. JAMA 235:1473-1474, 1976. 13. Goepfert JM, Spira WM, Kim HY: Bacillus cereus: Food poisoning organism: A review. J Milk Food Technol 35:213-227, 1972.
ers
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/03/2015
14. Francois JM: Le Bacille
thologie oculaire.
subtilique en pa¬ Optalmol
Bull Mem Soc Fr
47:423, 1934.
15. Pearson HE: Human infections caused by organisms of the Bacillus species. Am J Clin Pathol 53:506-515, 1970. 16. Van Bijsterveld OP, Richards RD: Bacillus infections of the cornea. Arch Ophthalmol 74:9195, 1965. 17. Greenspon EA: A pathogenic Bacillus
subtilis isolated from the eye. Am J Ophthalmol 1:316-318, 1918. 18. Reese AB, Khorazo D: Endophthalmitis due to subtilis following injury. Am J Ophthal¬ mol 26:1251-1253, 1943. 19. Davenport R, Smith C: Panophthalmitis due to an organism of the Bacillus subtilis group. Br J Ophthalmol 36:389-392, 1952. 20. Coonrod JD, Leadley PJ, Eickhoff TC: Antibiotic susceptibility of Bacillus species. J Infect Dis 123:102-105, 1971.
