RECALCITRANT MULTIDRUG-RESISTANT PSEUDOMONAS KERATITIS WITH
SUBSEQUENT TRIPLE PROCEDURE
Authors: Ēriks Elksnis1,2,4, Eva Elksne1,3, Olita Lūse1,2, Juris
Vanags1,4, Guna Laganovska1,4
Affiliations:
- Riga Stradins University, Riga, Latvia
- Latvian American Eye Center
- Children’s Clinical University Hospital, Riga, Latvia
- Pauls Stradins Clinical University Hospital
Correspondence to: Ēriks Elksnis. ORCID 0000-0002-7899-8224
Riga Stradins University, Dzirciema street 16, Riga, Latvia. LV1007.
Data availability statement : We hereby transfer, assign, or
otherwise convey all copyright ownership, including any and all rights
incidental thereto, exclusively to the journal, in the event that such
work is published by the journal
Conflict of interest disclosure : Authors declare no potential
conflicts of interest.
Ethics approval statement : All procedures performed involving
this case were in accordance with the ethical standards of the
institutional research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards.
Consent statement: Written informed consent was obtained from
the patient to publish this report in accordance with the journal’s
patient consent policy.
KEY CLINICAL MESSAGE
Recalcitrant Pseudomona aeruginosa keratitis is a challenging case in
ophthalmology and can lead to irreversible blindness if not treated
properly and in time.
KEYWORDS: Pseudomona aeruginosa, recalcitrant keratitis, penetrating
keratoplasty.
INTRODUCTION
Corneal opacity is the 5th leading cause of blindness
and visual impairment, affecting approximately 6 million people
worldwide; additionally, it is responsible for 1.5–2.0 million new
cases of monocular blindness per year. Among all etiologies (such as
infection, trauma, and inflammation), infectious keratitis (IK) is the
main cause of corneal blindness, with an estimated incidence ranging
from 2.5–799 per 100,000 population years (Ting et al. 2021).
Pseudomonas aeruginosa (P. aeruginosa ) is a gram-negative
aerobic pathogen that can cause a wide range of infections and is one of
the main causative pathogens of bacterial keratitis, especially in
contact lens-associated keratitis, potentially leading to
sight-threatening complications if not appropriately treated (Hilliam,
Kaye & Winstanley 2020).
A particular characteristic of multidrug resistant Pseudomonas keratitis
is its rapid progression, in which corneal destruction can be completed
within 24–48 hours in some of the more virulent bacterial strains
(Reynolds & Kollef 2021). Therefore, P. aeruginosa -caused
keratitis is often associated with a high-cost long treatment period and
poor visual outcomes (Hilliam, Kaye & Winstanley 2020).
CASE PRESENTATION
A 60-year-old female presented to a tertiary medical center in May 2021
with progressive vision loss, purulent discharge, photophobia, foreign
body sensation, and pain in the left eye (LE).
Three weeks prior, the patient developed a foreign body sensation in her
LE due to contact lenses remaining unremoved for one night. She had
visited her local ophthalmologist and been prescribed topical
tobramycin/dexamethasone 3 mg/mL four times daily, cyclopentolate 10
mg/mL twice daily, and dexpenthenolum once daily before bedtime. There
was clinical improvement during the first 5 days of therapy; however,
severe clinical worsening followed. The patient returned to the
outpatient department 8 days after the first consultation, and treatment
was changed to topical chloramphenicol/dexamethasone 1 mg/2 mg/mL six
times daily, cyclopentolate 10 mg/mL twice daily and oral doxycycline
100 mg twice daily. Despite treatment, the symptoms worsened in the
following week.
On the presenting day at the tertiary medical center, the best corrected
visual acuity (BCVA) was 20/25 in the right eye (RE) and hand-motion
(HM) vision in the LE. The RE was unremarkable on initial examination,
whereas slit-lamp examination of the LE revealed a massive amount of
purulent discharge in the conjunctival fornixes and intense mixed
conjunctival injection. A large epithelial defect in the cornea was
present, associated with a ring-like stromal infiltrate 3.1 mm in
height, which was “soupy” in appearance owing to stromal necrosis. A
hypopyon 3.2 mm in height was observed (Figure 1A). Both the lids were
swollen and erythematous. As the posterior segment could not be
visualized, B-scan ultrasonography of the LE was performed and confirmed
a flat retina with no vitritis.
Corneal scrapings and cultures were obtained from LE. Cultures were
acquired using a sterile cotton-tipped swab and placed in transport
medium. The scrapings were placed on a glass slide and, together with
the culture, forwarded to a microbiology laboratory.
Topical chloramphenicol/dexamethasone was discontinued, and levofloxacin
5 mg/mL eyedrops were initially administered every hour. Additionally,
cyclopentolate 10 mg/mL was administered twice daily to control pain and
prevent synechia, artificial tear drops were administered to aid wound
healing, and oral doxycycline 100 mg twice daily was administered to
prevent keratolysis.
After 12 hours, the condition worsened; discharge remained in the same
amount, however, the hypopyon increased to 5.4 mm in height, with an
infiltration spread 360 °around the limbus and significant corneal edema
(Figure 1B).
Levofloxacin was switched to moxifloxacin 5 mg/mL eye drops every hour.
As a result, the amount of purulent discharge reduced, yet the central
corneal infiltrate and ulcer remained unchanged, with remarkable stromal
necrosis and corneal thinning in the nasal limbs (Figure 1C).
On the fourth day from admission, multidrug resistantP.aeruginosa was isolated from the culture. (Table 1). Based on
these results, and after consultation with an infectologist,
moxifloxacin was changed to fortified piperacillin 1.5 mg/mL/tazobactam
12 mg/mL eye drops every hour.