This article is more than 5 years old. Information may no longer be current.
Young woman presents with nonresponding conjunctivitis
Click Here to Manage Email Alerts
A 20-year-old African American woman presented with a chief complaint of a moderately red, watery right eye with mucopurulent debris that started 4 days earlier. The patient denied recent fever, upper respiratory infection or sore throat. She reported being postpartum for approximately 6 weeks at this visit. She had a full-term vaginal birth without complications and was currently breastfeeding.
The medical history of the patient was positive for Goldenhar syndrome, which left her with facial and eyelid malformations. Previous surgeries to repair congenital heart defects, cleft lip/palate and eyelid surgeries were reported when she was an infant. Her congenital facial abnormalities and the surgical techniques attempted to correct these abnormalities left the patient with abnormal eyelid and conjunctival scarring and positioning. This resulted in poor appositional lid closure bilaterally. She denied any use of medications and any allergies to medications.
Best-corrected acuities were 20/200 in the right eye with a +7.50 DS lens and light perception only in the left eye with a plano lens via retinoscopy. Subjective refraction beyond this did not improve vision further in either eye. These acuities were stable from previous exams and consistent with her previous diagnosis of congenital, bilateral optic nerve atrophy. Her pupils were severely irregular in both eyes, with minimal reaction to light. Visual fields were restricted with confrontation in both eyes. Extraocular motilities were full, but a constant left esotropia was present.
IOP was measured at 14 mm Hg OD and 8 mm Hg OS with the iCare rebound tonometer. Anterior segment exam revealed irregular eyelid margins with incomplete blink and abnormal scarring and positioning of bulbar conjunctivas, with 4+ severe hyperemia of the right conjunctiva and mucopurulent discharge. There was no corneal staining noted at this exam in either eye with sodium fluorescein.
All exam findings were stable and previously noted at a recent comprehensive exam of the patient at our clinic, except for the 4+ severe conjunctival hyperemia and mucopurulent discharge now present in her right eye. She was provisionally diagnosed with bacterial conjunctivitis and empirically started on moxifloxacin eye drops, four times per day in the right eye and told to return to clinic in 1 week for follow-up.
The patient returned 1 week later as directed and reported negligible improvement from the previous visit. She reported that she ran out of the medication after 2 days of use. The mucopurulent discharge and redness was unchanged at this exam in the right eye, while the left eye remained uninvolved. There was concern that the patient had difficulty determining the amount of medication remaining in the bottle due to her reduced vision and the highly viscous nature of the medication. Therefore, the moxifloxacin eye drops were discontinued, and lid scrubs were initiated with polymyxin B/trimethoprim eye drops every 3 hours in the right eye. The patient was directed to follow up in 2 days.
She returned as directed 2 days later again, with slight improvement in her signs and symptoms. Fluorometholone 0.1% suspension was started four times per day in the right eye to help improve her symptoms, and the polymyxin B/trimethoprim eyedrops were continued at every 3 hours in the right eye to give it a longer opportunity to become efficacious. The patient was directed to follow up in 5 days. However, upon re-examination 5 days later, minimal improvement was once again seen.
What’s your diagnosis?
Please see answer on the next page.
We elected to culture the patient’s nonresponsive mucopurulent conjunctivitis with routine culture swabs and submitted the sample to a local laboratory for both susceptibility testing and identification of the offending microbe. Approximately 1 week later, the culture results identified the offending organism as “beta-hemolytic Streptococcus pyogenes group A,” which was reported to be uniformly susceptible to penicillin antibiotics. Therefore, we elected to initiate oral treatment with 500 mg amoxicillin with clavulanic acid two times per day by mouth for 10 days. The patient reported no side effects with treatment and complete resolution of her conjunctivitis at her last follow-up 14 days later after treatment.
Beta-hemolytic S. pyogenes belongs to the serological group A among streptococci and is an exclusively human pathogen. It is also referred to commonly as Group A Streptococcus (GAS) species. GAS is considered a catalase-negative aerobic gram-positive coccus. It is most commonly associated with pharyngitis, and this is the preferred location for colonization by the bacteria and also serves as the primary reservoir for transmission to other people. Transmission among individuals involves direct contact as well as exposure to respiratory droplets. Interestingly, GAS infections can also result from foodborne transmission.
Risk factors
Risk factors for adult GAS infection include diabetes mellitus; malignancies; alcoholism; steroid use; chronic heart, lung, liver or renal diseases; HIV infection and IV drug use. Postpartum status was likely important for our patient, as it is a risk factor for bacterial infections in general. Pregnant women are more susceptible to upper respiratory tract infections due to fluctuations in their immune systems. In comparison to nonpregnant women, postpartum patients have a 20-fold increased incidence of GAS infections (Mason et al.). Additionally, pregnancy-related GAS infections appear to be increasing in prevalence.
The following systemic conditions have also been implicated with GAS infections: pyoderma, impetigo, bacteremia, acute rheumatic fever, rheumatic heart disease, glomerulonephritis, endocarditis, streptococcal toxic shock syndrome and even death in severe cases. Rare ocular infections and complications secondary to GAS have been reported in the literature. These include: recurrent conjunctivitis, preseptal necrotizing fasciitis, corneal ulceration, iritis, orbital cellulitis, endophthalmitis and acute posterior multifocal placoid pigment epitheliopathy (Bachman et al.).
Rare ocular infection
GAS infections are considered to be uncommon in pediatric patients and even rarer in cases of adult bacterial conjunctivitis. One study of 273 eyes with conjunctivitis (Perkins et al.) and another study with 409 eyes with conjunctivitis (Seal et al.) failed to recover GAS in their respective study populations. In a study of 579 elderly pre-phacoemulsification eyes without conjunctivitis, there were no eyes that showed positive culture results of GAS (Suto et al.). These studies help underscore the rarity of the presence of GAS on the ocular surface, which is peculiar given how commonly pharyngitis is caused by GAS (up to 30% of cases and more than 616 million cases per year globally) (Anjos et al.).
The most common bacteria responsible for acute bacterial conjunctivitis in adults has been reported to be: Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus pneumoniae. Distinguishing between various bacterial etiologies requires culturing, which is indicated in severe or nonresponsive cases of bacterial conjunctivitis.
Treatment
GAS have many defensive mechanisms against the human immune system including: degradation and inhibition of immunoglobulins and complement, adhesive matrix molecules to help attach to host cells, uncoupling of coagulation and cytotoxic/cytolytic activity toward host cells. These mechanisms can also incite a significant inflammatory response via potent exotoxins in the form of corneal pannus/neovascularization, intraocular inflammation and necrotizing fasciitis. Topical corticosteroid medications, in conjunction with appropriate topical or oral antibiotics, can be helpful when significant ocular inflammation is encountered.
Penicillin-based antibiotics remain the best therapeutic agent to treat GAS infections. Other reported treatment options could include: azithromycin, fluoroquinolone antibiotics, cephalosporins, clindamycin or vancomycin. Notably, there have been no reports of penicillin-resistant cases. However, there is increasing GAS resistance worldwide to erythromycin, azithromycin and clindamycin. Therefore, erythromycin (a macrolide antibiotic) should be avoided in cases of GAS-associated conjunctivitis. If allergy to penicillin is reported by the patient, an alternative treatment option would be azithromycin, as it has comparable efficacy in comparison to penicillin, despite it being part of the macrolide class of antibiotics.
Based on this information, instead of oral Augmentin (amoxicillin and clavulanic acid, GlaxoSmithKline) used in this case, perhaps topical AzaSite (azithromycin 1%, Akorn) or oral Zithromax Z-pak (azithromycin, Pfizer) might have been good options to consider if the patient had reported a penicillin sensitivity.
Underlying Goldenhar syndrome
One additional important clinical factor to remember in this case was the patient’s underlying Goldenhar syndrome, which is a disorder resulting from abnormalities during embryonic development of the first and second brachial arch. It appears to be a sporadic development, with most cases having no family members with the condition.
Signs and symptoms vary markedly among those who are affected. Some signs of the condition include facial asymmetry, microtia, underdeveloped facial muscles and bones, cleft lip or palate, dental abnormalities, anophthalmia or microphthalmia, epibulbar tumors, retinal abnormalities and vision loss. In most cases, only one side of the face is affected, although bilateral involvement has been reported (Touliatou et al.). Abnormal ocular anatomy, often present in Goldenhar syndrome, can lead to ocular surface disease, which has been demonstrated to be a risk factor for ocular bacterial infection (Teweldemedhin et al.). Therefore, we feel that this patient’s postpartum status and her underlying eyelid abnormalities secondary to her Goldenhar syndrome diagnosis likely helped nurture her nonresponsive infection
Importance of culturing
This case report is significant as it highlights the importance of culturing ocular bacterial infections that do not respond well to empiric antibiotic treatment regimens. Unfortunately, we could not identify the initial source of the patient’s GAS infection during her treatment period.
Pregnant and nursing mothers require sound antibiotic prescribing practices to prevent potential side effects to the nursing infant as well as eradicating the offending pathogen. Oral antibiotics in nursing mothers can lead to rare complications with their nursing infants that can include: possible allergic reaction, alteration of the bowel flora that can lead to gastrointestinal upset (ie, diarrhea), possible reduction in gut nutrient absorption and possible interference with blood cultures of infants. However, amoxicillin with clavulanic acid is considered “safe for administration” with breastfeeding, although combining precautionary approaches have been outlined in several sources to reduce risk to the nursing infant (Mathew). These potentially include: topical antibiotic treatment, avoiding nursing at peak plasma concentrations, formula feeding during antibiotic treatment duration and close monitoring of the infant for potential implications. Of course, when in doubt, a quick phone call to the infant’s pediatrician is advised.
At approximately 9 months post-treatment, the patient has experienced no recurrence after proper identification and treatment of her ocular infection.
- References:
- Anjos LMM, et al. Rev Soc Bras Med Trop. 2014;47:409-413.
- Bachman JA, et al. Optometry. 2002;73:303-310.
- Fiedler T, et al. Front Cell Infect Microbiol. 2015;doi:10.3389/fcimb.2015.00015.
- Mason KL, et al. Am J Reprod Immunol. 2012;doi:10.1111/j.1600-0897.2011.01083.
- Mathew JL. Postgrad Med J. 2004;doi:10.1136/pgmj.2003.011973.
- Perkins RE, et al. J Clin Microbiol. 1975;1:147-149.
- Seal DV, et al. Br J Ophthalmol. 1982;66:357-360.
- Suto C, et al. Infect Drug Resist. 2012;doi:10.2147/IDR.S27937.
- Teweldemedhin M, et al. Infect Dis. 2017;doi:10.1186/s12879-017-2304-1.
- Touliatou V, et al. Genet Couns. 2006;17: 359-370.
- Wong SSY, et al. Emerg Microbes Infect. 2012;doi:10.1038/emi.2012.9.
- For more information:
- Chris Borgman, OD, is an assistant professor at the Southern College of Optometry in Memphis. He can be reached at: cborgman@sco.edu.
- Taylor Kiser, OD, is an assistant professor at the Southern College of Optometry. She can be reached at: tkiser@sco.edu.
- Michael Gerstner, OD, is a professor at the Southern College of Optometry. He can be reached at: gerstner@sco.edu.
- Edited by Leo P. Semes, OD, FAAO, a Primary Care Optometry News Editorial Board Member and Professor Emeritus in the Department of Optometry and Vision Science at the University of Alabama at Birmingham. He can be reached at: leopsemes@gmail.com.
Disclosures: The authors reported no relevant financial disclosures.