Case Report

Rare cause of acute postoperative endophthalmitis:Gemella morbillorum

Guven, Soner MD*; Kucukevcilioglu, Murat MD; Durukan, Ali Hakan MD; Aykas, Seckin MD; Guney, Mustafa MD

Author Information
Journal of Cataract and Refractive Surgery Online Case Reports: July 2018 - Volume 6 - Issue 3 - p 40-42
doi: 10.1016/j.jcro.2018.02.003
  • Free

Abstract

Endophthalmitis is the most serious postoperative complication. Fortunately the incidence of postoperative endophthalmitis after cataract surgery is low, approximately 0.043%.1 The most common organisms reported in previous studies are gram-positive staphylococci and streptococci.2,3 We report a rare case of severe Gemella morbillorum endophthalmitis after cataract surgery that resulted in no light perception (NLP).

CASE REPORT

A 73-year-old nondiabetic, hypertensive woman with hypercholesterolemia presented with a 2-day history of decreased vision, pain, redness, and eyelid swelling in the right eye. She had uneventful phacoemulsification with intraocular lens implantation in the right eye 5 days previously. The protocol at the hospital is to not routinely administer preoperative antibiotics to cataract patients but rather to apply povidone–iodine (Betadine) 3 times intraoperatively, wait at least 3 minutes, and then administer intracameral cefuroxime before completing surgery.

On examination, the patient's corrected distance visual acuity (CDVA) was uncertain light perception in the right eye and 20/30 in the left eye. The intraocular pressure (IOP) was 22 mm Hg in the right eye and 14 mm Hg in the left eye. A slitlamp examination showed conjunctival hyperemia, corneal lytic lesions in the upper corneal limbus, a semiopaque cornea with corneal edema, 3+ cells and dense flare in the anterior chamber, and ectopia of the superior pupil in the right eye (Figure 1). Because of the decreased clarity of the cornea and anterior chamber, evaluation of the direct pupillary light reflex could not be evaluated properly. The consensual pupillary light reflex was preserved. A B-scan ultrasound (US) showed vitreous debris with an attached retina. The left eye was unremarkable except for trace nuclear sclerosis.

Figure 1.
Figure 1.:
Anterior segment photograph 5 days after cataract surgery.

The clinical diagnosis was acute postoperative endophthalmitis. A pars plana vitrectomy (PPV) was performed on the same day, and an undiluted vitreous sample was obtained at the beginning of surgery. The vitreous cavity was full of white debris with an ischemic fragile retina and widespread retinal hemorrhages. The optic disc was pale with regular disc borders. The vitreous cavity was irrigated with vancomycin and amikacin, and 1000 centistoke silicone oil was injected as a tamponade. After surgery, topical moxifloxacin, vancomycin 0.5%, amikacin, and prednisolone acetate 1.0% eyedrops were started every 2 hours and cyclopentolate 1.0% eyedrops 3 times a day. The first day after the PPV, the anterior segment was relatively clear and the retina was pale but detached. Two days later, the patient's IOP was 10 mm Hg in the right eye but the CDVA had decreased to NLP.

Preliminary Gram staining suggested a gram-negative diplococcus. The microbiologists later confirmed grown colonies were gram-positive to variable, oxidase-negative, and catalase-negative cocci. A Phoenix automated identification device (identification rates 96% and 98%) (Becton, Dickinson and Co.) and matrix-assisted laser desorption ionization: time of flight mass spectrometry (MALDI-TOF MS, Bruker Daltonics Inc.) (identification scores 2086 and 2131) identified G morbillorum (Figure 2). Because G morbillorum is an unusual pathogen, the bacterial identification procedures were repeated. The result was confirmed. The minimum inhibitory concentration (MIC) levels of tigecycline, tetracycline, doxycycline, co-trimoxazole, ciprofloxacin, clarithromycin, penicillin G, gentamicin, daptomycin, vancomycin, teicoplanin, cefotaxime, ceftriaxone, linezolid, imipenem, and meropenem were evaluated using the exponential gradient method (E-test) (Table 1). As expected for anaerobes, MIC levels were high against ciprofloxacin, co-trimoxazole, and gentamicin. For other antimicrobial agents (except daptomycin), the MIC levels were lower. The treatment protocol was shared with the microbiology department, which did not advise additional medication. One week later, although the inflammation showed signs of resolution after the treatment with a relatively calm anterior chamber, a retinal detachment was detected on B-scan US. However, because of the guarded prognosis, further surgery was not performed.

Figure 2.
Figure 2.:
Gram staining of the bacteria (Gemella morbillorum).
Table 1
Table 1:
Minimum inhibitory concentration levels of Gemella morbillorum (E-test).

DISCUSSION

Gemella morbillorum is a member of Gemella species, which is a facultative anaerobic catalase-negative gram-positive coccus. Tunnicliff4 isolated this organism from the throat and nose of patients with measles in 1917. Laboratory identification is difficult because it looks like the viridans-type of streptococci and the Gram stain results are variable. As in the present case, sometimes gram-negative staining can appear.5 There are only 5 reported cases of various eye infections caused by G morbillorum in the literature.6–8Table 2 shows all reported cases of Gemella species.5–15

Table 2
Table 2:
Summary of all reported cases of ocular involvement of Gemella species.

Hamrah et al.7 reported 2 cases, 1 of which was a postoperative endophthalmitis, after penetrating keratoplasty and vitrectomy. The patient recovered very well after a PPV was performed and an intraocular injection of vancomycin. The other case had purulent conjunctivitis and was treated successfully. Ascaso et al.6 reported acute postoperative (cataract surgery) endophthalmitis in a patient who had a history of prolonged antibiotic therapy and active gingivitis. This is the second report related to acute post-cataract surgery endophthalmitis caused by G morbillorum. Nalamada et al.12 reported a similar case of acute postoperative endophthalmitis after cataract surgery; however, the causative pathogen was G haemolysans. Recently, Salceanu et al.13 reported a case of endophthalmitis after a ranibizumab intravitreal injection in which the responsible agent was also G haemolysans. That case was a 92-year-old woman with wet age-related macular degeneration and relatively limited visual potential. Although all other cases of ocular Gemella infections mentioned, except for Salceanu et al.'s case, ended with favorable vision, our patient had NLP at the last examination. Salceanu et al.13 argued that the poor visual acuity in their report was the result of the late presentation of the patient, the bacterial pathogenicity, and the development of pupillary block glaucoma. In our case, the possible cause of the negative outcome could be the excessive bacterial load. During surgery, the view of the retina showed it was severely affected. This could be another possible cause of the patient's unresponsiveness to the treatment.

There is no proof that shows Gemella species are resistant to povidone–iodine or other antiseptics. Although it is thought that the organism is susceptible in vitro to penicillin, streptomycin, vancomycin, chloramphenicol, and tetrasulfathiazole, the in vivo response can be controversial.7 The present case progressively worsened despite agent-targeted therapy.

Disclosures:

None of the authors has a financial or proprietary interest in any material or method mentioned.

REFERENCES

1.Lloyd JC, Braga-Mele R. Incidence of postoperative endophthalmitis in a high-volume cataract surgicentre in Canada. Can J Ophthalmol 2009; 44:288-292
2.Shrader SK, Band JD, Lauter CB, Murphy P. The clinical spectrum of endophthalmitis: incidence, predisposing factors, and features influencing outcome. J Infect Dis 1990; 162:115-120
3.Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study; a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113:1479-1496
4.Tunnicliff R. The cultivation of a micrococcus from blood in pre-eruptive and eruptive stages of measles. J Am Med Assoc 1917; 68:1028-1030
5.Raman SV, Evans N, Freegard TJ, Cunningham R. Gemella haemolysans acute postoperative endophthalmitis [letter]. Br J Ophthalmol 2003; 87:1192-1193. Available at: http://bjo.bmj.com/content/bjophthalmol/87/9/1192.2.full.pdf. Accessed May 8, 2018
6.Ascaso FJ, Cardeñosa E, Cascante JM, Lario B, Pérez D, Cristóbal JA. Acute postoperative endophthalmitis caused by Gemella morbillorum. Eur J Ophthalmol 2010; 20:608-611. Available at: http://journals.sagepub.com/doi/pdf/10.1177/112067211002000314. Accessed May 8, 2018
7.Hamrah P, Ritterband D, Seedor J, Eiferman RA. Ocular infection secondary to gemella. Graefes Arch Clin Exp Ophthalmol 2006; 244:891-892
8.Sawada A, Mochizuki K, Katada T, Kawakami H, Yamamoto T, Mikamo H, Watanabe K. Gemella species-associated late-onset endophthalmitis after trabeculectomy with adjunctive mitomycin C. J Glaucoma 2009; 18:496-497
9.Kailasanathan A, Anderson DF. Infectious crystalline keratopathy caused by Gemella haemolysans. Cornea 2007; 26:643-644
10.Rial L, Schargel K, Rial A, Ortega L, Belda JI. Late-onset Gemella morbillorum flap-margin-related keratitis after laser in situ keratomileusis. J Clin Case Rep 2016; 6:885. Available at: https://www.omicsonline.org/open-access/lateonset-gemella-morbillorum-flapmarginrelated-keratitis-after-laserin-situ-keratomileusis-2165-7920-1000885.pdf. Accessed May 8, 2018
11.Ritterband D, Shah M, Kresloff M, Intal M, Shabto U, Seedor J. Gemella haemolysans keratitis and consecutive endophthalmitis. Am J Ophthalmol 2002; 133:268-269. Available at: https://www.ajo.com/article/S0002-9394(01)01271-5/pdf. Accessed May 8, 2018
12.Nalamada S, Jalali S, Reddy AK. Acute postoperative endophthalmitis by Gemella haemolysans. Indian J Ophthalmol 2010; 58:252-253. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886264/?report=printable. Accessed May 8, 2018
13.Salceanu SO, Levy S, Cunningham R, Frimpong-Ansah K. Severe Gemella haemolysans endophthalmitis following ranibizumab intravitreal injection. Indian J Ophthalmol 2017; 65:1249-1251. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700611/?report=printable. Accessed May 8, 2018
14.Sen E, Evren E, Elgin U. Canaliculitis due to Gemella Haemolysans and Porphyromonas Asaccarolytica. Gazi Med J 2015; 26:183-184. Available at: http://www.medicaljournal.gazi.edu.tr/index.php/GMJ/article/viewFile/1151/1054. Accessed May 8, 2018
15.Cornut PL, Youssef EB, Bron A, Thuret G, Gain P, Burillon C, Romanet JP, Vandenesch F, Maurin M, Creuzot-Garcher C, Chiquet C, for the French Institutional Endophthalmitis Study (FRIENDS) Group. A multicentre prospective study of post-traumatic endophthalmitis. Acta Ophthalmol 2013; 91:475-482. Available at: https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1755-3768.2011.02349.x. Accessed May 8, 2018
© 2018 by Lippincott Williams & Wilkins, Inc.
Data is temporarily unavailable. Please try again soon.