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  • Because of worsening of the peripheral ulcer (Figure 1), conjunctival and corneal biopsies were performed 1 month later. The result of the Gram stain was negative, and bacterial cultures remained sterile. However, the auramine O fluorescent and Ziehl-Neelsen stains revealed a few acid-fast bacilli (Figure 2). The histological features showed a granuloma with early central necrosis (Figure 3). Mycobacteria were recovered from cultures (BACTEC 12B; Becton Dickinson, Sparks, Mass) after 14 days of incubation at 37C. These were subsequently identified as M szulgai by polymerase chain reactionrestriction fragment length polymorphism analysis and by conventional methods. Minimum inhibitory concentrations were determined using a modification of the microbroth dilution method described by Yajko et al. The in vitro susceptibility of M szulgai is as follows: Figure 1. Slitlamp picture of the left cornea showing a peripheral corneal ulcer and a heavily vascularized nodule. Figure 2. High-power illustration of acid-fast bacilli (Ziehl-Neelsen, original magnification 1000). Figure 3. High-power photomicrograph of the excised conjunctiva shows chronic granulomatous inflammation (hematoxylin-eosin, original magnification 200). Drug Minimum Inhibitory Concentration, mg/L Amikacin 2.000 Clarithromycin 0.250 Ciprofloxacin 0.250 Rifabutin 0.500 Ethambutol hydrochloride 2.000 Topical corticosteroids were discontinued, and the treatment was changed to ciprofloxacin hydrochloride, 5 times daily, and amikacin, 20 mg/mL, 4 times daily. Clarithromycin drops, 20 mg/mL, were prepared according to the method of Helm et al, but were not tolerated and had to be discontinued after a few days. Clarithromycin (Klacid), 500 mg twice daily, was given orally for 3 months. Clinically, the inflammation subsided during the following 3 weeks, the epithelial erosion healed, and a vascularized scar formed. Eleven months after the biopsy and 3 months after discontinuation of topical treatment, the best-corrected visual acuity is 20/25 OD and the eye is not inflamed. COMMENT To our knowledge, this is the first reported case of keratitis due to M szulgai. The keratitis healed with topical and systemic treatment, and a final visual acuity of 20/25 OD was attained. The patient was immunocompetent and did not wear contact lenses, but had been treated with topical corticosteroids for several months before he was first seen by us. Mycobacterium szulgai is an unusual pathogen that accounts for less than 1% of all cases of nontuberculous mycobacteria infections. Diseases caused by this slow-growing mycobacterium usually involve the lung but may also lead to infections of soft tissue and bone. In our case, in vitro susceptibility testing showed rather low minimum inhibitory concentrations to clarithromycin and ciprofloxacin. Because topical clarithromycin was not well tolerated, amikacin was also used. The in vitro susceptibility of mycobacteria to antibiotics is different from that in vivo and may not predict the effectiveness of topical antibiotics. This may explain why the keratitis healed despite the fact that we did not use the optimal drug combination as indicated by the minimum inhibitory concentrations. This case underscores the importance of performing corneal biopsies to detect unusual pathogens in patients with therapy-resistant keratitis. JG Ford JW Huang SC Pflugfelder EC Alfonso RK Forster D Miller Nontuberculous mycobacterial keratitis in south Florida. Ophthalmology. 1998;105:1652-1658. RH Bullington Jr JD Lanier RL Font Nontuberculous mycobacterial keratitis: report of two cases and review of the literature. Arch Ophthalmol. 1992;110:519-524. N Sossi RM Feldman ST Feldman BE Frueh G McGuire C Davis Mycobacterium gordonae keratitis after penetrating keratoplasty. Arch Ophthalmol. 1991;109:1064-1065. A Telenti F Marchesi M Balz F Bally EC Bottger T Bodmer Rapid identification of mycobacteria to the species level by polymerase chain reaction and restriction enzyme analysis. J Clin Microbiol. 1993;31:175-178. PT Kent GP Kubica Public Health Mycobacteriology: A Guide for the Level II Laboratory. Atlanta, Ga: US Dept of Health and Human Services, Public Health Service; 1985. DM Yajko PS Nassos WK Hadley Broth microdilution testing for susceptibilities to 30 antimicrobial agents of Mycobacterium avium strains from patients with acquired immune deficiency syndrome. Antimicrob Agents Chemother. 1987;31:1579-1584. CJ Helm GN Holland R Lin OGW Berlin DA Bruckner Comparison of topical antibiotics for treating Mycobacterium fortuitum keratitis in an animal model. Am J Ophthalmol. 1993;116:700-707. DA Benator V Kann FM Gordin Mycobacterium szulgai infection of the lung: case report and review of an unusual pathogen. Am J Med Sci. 1997;313:346-351. Accepted for publication February 11, 2000. Reprints: Beatrice E. Frueh, MD, Department of Ophthalmology, Inselspital, 3010 Bern, Switzerland (e-mail: beatrice.frueh@insel.ch).
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  • Rights Holder:
  • JAMA
  • License Rights Holder:
  • Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
  • Asset Type:
  • Image
  • Asset Subtype:
  • Illustration
  • Image Orientation:
  • Landscape
  • Image Dimensions:
  • 590 x 403
  • Image File Size:
  • 43.5 KB
  • Creator:
  • Beatrice E. Frueh MD, Olivier Dubuis MD, Pascal Imesch MD, Matthias Bhnke MD, Thomas Bodmer MD
  • Credit:
  • Frueh, B. E., Dubuis, O., Imesch, P., Bhnke, M., & Bodmer, T. (2000). Mycobacterium szulgai Keratitis. , 118(8), 1123-1124. https://doi.org/10.1001/archopht.118.8.1123.
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  • Property Release:
  • No
  • Model Release:
  • No
  • Purchasable:
  • Yes
  • Sensitive Materials:
  • No
  • Article Authors:
  • Beatrice E. Frueh MD, Olivier Dubuis MD, Pascal Imesch MD, Matthias Bhnke MD, Thomas Bodmer MD
  • Article Copyright Year:
  • 2000
  • Publication Title:
  • Publication Volume:
  • 118
  • Publication Issue:
  • 8
  • Publication Date:
  • 08/01/2000
  • DOI:
  • https://doi.org/10.1001/archopht.118.8.1123

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