|Year : 2019 | Volume
| Issue : 1 | Page : 24-26
Keratoactinomycosis: A rare case report
Pradnya Krishnakant Bhole, Dipali P Parmar
Department of Ophthalmology, M and J Western Regional Institute of Ophthalmology, Ahmedabad, Gujarat, India
|Date of Submission||17-Mar-2018|
|Date of Acceptance||22-Aug-2018|
|Date of Web Publication||12-Mar-2019|
Pradnya Krishnakant Bhole
Department of Ophthalmology, M and J Western Regional Institute of Ophthalmology, B J Medical College Campus, C/34, Sanjay Tower, Shyamal Cross Roads, Ahmedabad - 380 015, Gujarat
Source of Support: None, Conflict of Interest: None
A 50-year-old female farmer, with a history of vegetative trauma, presented to a tertiary eye care center, with right eye ulcerative keratitis, initially treated elsewhere as fungal keratitis, refractory to conventional antifungal therapy. A corneal scraping was done and it revealed Gram-positive filamentous Actinomyces bacteria. Treatment with topical penicillin (100,000 U/ml) showed a complete resolution of the corneal infection, within 2 weeks of therapy. Actinomyces keratitis is a rare clinical condition. A history of ocular vegetative trauma, with a clinical picture similar to fungal keratitis, leads to delay in the diagnosis of such rare presentations of posttraumatic keratoactinomycosis, which otherwise shows a good response to topical penicillin therapy. A corneal scraping done helps in timely diagnosis and effective treatment.
Keywords: Keratoactinomycosis, penicillin, scraping
|How to cite this article:|
Bhole PK, Parmar DP. Keratoactinomycosis: A rare case report. J Clin Ophthalmol Res 2019;7:24-6
Actinomycetes are true Gram-positive bacteria; they are anaerobic nonsporing, noncapsulated, non acid-fast filaments that bear superficial resemblance to fungi. Most are free living, particularly in the soil. Actinomycetes have been reported as a causative organisms of eye infection in keratitis, canaliculitis (Actinomyces israelii), conjunctivitis, blepharitis, postsurgical endophthalmitis, and porous orbital implant infection.
Actinomycosis is a rare cause of ulcerative keratitis. A primary corneal ulcer attributed to Actinomyces species usually follows corneal trauma. Actinomyces keratitis typically presents as a dry-looking ulcer with necrotic bed, surrounded by a yellow demarcating gutter. The ulcer tends to progress slowly, but ultimately necrosis may lead to descematocoele, followed by perforation. Associated inflammation can be severe with iritis and hypopyon. Actinomycetes are usually susceptible to penicillins and cephalosporins. Prognosis is good, once the organism is positively identified and appropriately treated. Hence, an immediate identification of the organism is essential to institute timely appropriate treatment and avoid a surgical intervention.
A few cases of actinomyces keratitis, with variable outcomes, have been reported in the scientific literature. We report a rare case of posttraumatic keratoactinomycosis with a good response to topical penicillin therapy.
| Case Report|| |
A 50-year-old female farmer presented with pain, redness, discharge, watering, photophobia, and diminished vision in the right eye (RE), for 10 days, following vegetative trauma. She was diagnosed elsewhere as fungal keratitis, based on clinical suspicion and was started on natamycin 5% eye drops 1 hourly, with topical cycloplegics and oral fluconazole. She showed no improvement with the treatment.
Visual acuity in the RE at presentation was HM + PL + PR4+ and the left eye (LE) had 6/9 with spectacle correction. On slit-lamp biomicroscopy examination of RE, lid edema and purulent discharge were noted. This was associated with diffuse and circumcorneal congestion and follicular papillary response in the palpebral conjunctiva. A dry-looking corneal ulcer, approximately 4 mm × 3 mm, with deep stromal infiltration in its bed was noted. Peripheral corneal vascularization involving almost the entire circumference of cornea was noted. The limbal tissue adjacent to the ulcer was markedly inflamed. The anterior chamber was of normal depth with associated marked iritis and hypopyon of approximately 1.5 mm. The pupil was semidilated and not reacting to light (under the effect of topical cycloplegic) and pseudophakia was present [Figure 1]. LE was found to be normal. Ultrasonography of the affected eye and a complete blood count with blood sugar levels were found to be normal.
|Figure 1: Clinical presentation – Corneal ulcer with stromal infiltration with adjoining limbal inflammation|
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A corneal scraping, under aseptic precautions, from the edges and the bed of the ulcer was done and subjected to 10% potassium hydroxide wet mount and Gram staining. The corneal scraping report revealed Gram-positive filamentous bacteria, namely Actinomyces [Figure 2] and [Figure 3].
Depending upon the microbiological report, the patient was started on topical penicillin eye drops (100,000 U/ml) along with topical preservative-free artificial tear substitutes and cycloplegic drops. This was accompanied by systemic oral administration of a combination of 500 mg amoxicillin and 125 mg clavulanic acid twice a day for 5 days and analgesic anti-inflammatory tablets.
The patient responded well to this treatment and showed a decrease in the infiltration within 48–72 h of the start of treatment. The size of the ulcer started reducing with a resolution of hypopyon in around 1 week. The ulcer resolved with scar formation within 2 weeks of the start of treatment [Figure 4] and [Figure 5].
|Figure 4: At 5 days – Decrease in the size of corneal ulcer with resolution of iritis and hypopyon|
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| Discussion|| |
Few cases of actinomyces keratitis have been reported in the literature till date. In a case reported in 1989 by Singh M and Kaur B in Malaysia, actinomyces keratitis developed in the absence of any known ocular trauma. It showed a dramatic response to penicillin therapy.
Another case reported in 2008 by Karimian et al. in Iran had unilateral A. israelii keratitis in the corneal interface, 5 months after laser in situ keratomileusis, which responded well to topical antibiotics.
In 2009, two cases reported by Andrés Emanuelli et al. in Puerto Rico had a history of vegetative trauma and a presentation of over 1 week after the trauma, suggesting the slow growth of Actinomyces, similar to fungal keratitis. Patients were misdiagnosed as fungal keratitis until cultures suggestive of Actinomyces were available. Delay in diagnosis and initiation of the appropriate treatment lead to the need of penetrating keratoplasty in both the cases.
In our case report too, an initial antifungal therapy was started elsewhere, on suspicion of fungal keratitis, but it proved ineffective. Only after the patient presented to our center, and after the scraping report revealed Actinomyces, did the patient respond favorably to the specific penicillin therapy.
Clinically, actinomyces keratitis may resemble nocardia keratitis and it should also be considered in the differential diagnosis, although it presents predominantly with anterior stromal infiltrates.
Even in clinical situations of doubt, microbiological investigation helps to confirm the diagnosis. A corneal scraping smear showing beaded Gram-positive partially acid-fast branching filaments is highly suggestive of nocardia. Actinomyces is nonacid fast.
We report this case to alert the clinician of an uncommon cause of ulcerative keratitis that can be destructive, if treatment is delayed, but seems to be responsive to appropriate and timely diagnosis by corneal scraping guiding proper treatment and also to highlight the importance of a good microbiological setup for accurate diagnosis.
Actinomyces should be suspected in the presence of slow-growing posttraumatic corneal ulcers with fungal resemblance, in the absence of positive cultures, and in the patient who is not responding to antifungal therapy as expected. Once the diagnosis is made, treatment is effective with topical and systemic penicillin or cephalosporins.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent fpr her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be gauranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]