Listeria monocytogenes
Endophthalmitis
Adolfo G. Bagnarello, MD; Allison J. Berlin, MD; Allan J. Weinstein, MD; Martin C. McHenry, MD; Patrick S. O'Connor, MD
\s=b\ Listeria
monocytogenes and
phylococcus organism caused
a a
strophic endophthalmitis in a patient despite appropriate local and systemic antimicrobial chemotherapy. Although L monocytogenes is widespread in nature and has produced a variety of clinical illnesses, It has only once previously been reported to cause endophthalmitis. If appropriate microbiologic techniques are not employed, the organism may go unrecognized as an ocular pathogen. (Arch Ophthalmol 95:1004-1005, 1977)
Infections
due to Listeria monocytogenes have been described with
increasing frequency
in
recent
years.'3 While Listeria infections in newborn children have long been
recognized/ the organism has only rarely been appreciated to be a pathogen in adults in whom host
defense mechanisms have not been altered, either by malignancy or immunosuppressive therapy. It is the purpose of the present report to describe a patient with apparently normal host defenses in whom L
monocytogenes played
important pathogenesis of endophthalmitis. To our knowledge, this is an
role in the
the second case in which L monocytogenes has been responsible for endophthalmitis, either alone or in concert with other ocular pathogens.
publication Sept 24, 1976. From the Departments of Infectious Disease (Drs Bagnarello, Weinstein, and McHenry) and Ophthalmology (Drs Berlin and O'Connor), Cleveland Clinic Foundation, Cleveland. Reprints not available.
Accepted
for
REPORT OF A CASE
stacata-
A 68-year-old farmer developed redness, photophobia, and pain in the right eye
during the last week of June 1975. Despite topical and systemic antimicrobial chemotherapy and anti-inflammatory therapy, the patient's symptoms progressed; on July 22, 1975, he was referred to the Cleveland Clinic Hospital for further evaluation.
The blood pressure was 170/95 mm Hg, the pulse rate was 76 beats per minute, the respiratory rate was 12/min, and the temperature was 36.5 C, orally. Findings from a complete physical examination were within normal limits except for the right eye. Visual acuity in the right eye was limited to light perception only, the conjunctiva was hyperemic, and there was marked chemosis. A large central epithelial abrasion of the cornea was associated with marked (4 + ) epithelial edema, central horizontal striae, and large keratic precipitates on the posterior surface. The anterior chamber was almost completely occluded by a dense hypopyon. The iris was widely dilated, and details of the iris were visible only at the superior pole of the eye. The posterior segment was not visible. The intraocular pressure in the right eye was 68 mm.
Results of initial laboratory studies, including hemoglobin, leukocyte count, and tests of renal and hepatic function, were
normal. Blood cultures were sterile. The blood glucose level was 288 mg/100 ml at two hours during a standard glucose tolerance
test.
Under aseptic technique, a paracentesis of the anterior chamber of the right eye was performed. Gram-stain of the turbid fluid demonstrated numerous polymorpho-
nuclear leukocytes, Gram-positive bacilli, and Gram-positive cocci. Cultures of this fluid yielded L monocytogenes and St.aphylococcux epidermidis. Identification of S epiderm.id.is was performed according to routine bactériologie criteria.1 Listeria
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/13/2015
monocytogenes was identified on the basis of the following observations: the organism was a pleomorphic Gram-positive bacillus that produced /)-hcmolysis on sheep blood agar. It was motile at 37 C and at room temperature, but not at 40 C. The catalase reaction was positive, while the oxidase reaction was negative. The organism fermented glucose, maltose, trehalose, and salicin, but failed to ferment sucrose, lactose, dulcitol, and mannitol. The minimal inhibitory concentration of ampicillin for this organism was less than 0.1
ug/ml.
patient was treated with ampicillin, intravenously every 4 hours for 18 days, methicillin, 2 mg intravenously every 4 hours for 14 days, gentamicin, 100 mg intravenously every 8 hours for 5 days, and sub-Tenon's methicillin, 100 mg daily for 7 days. In addition, topical dexamethasone and atropine were administered. The patient was discharged from the hospital The
2 gm
when there was apparent resolution of the hypopyon of the anterior chamber. However, the visual acuity in the right eye was limited to light perception only. On discharge from the hospital, the patient was placed on a regimen of oral ampicillin and topical gentamicin. Eleven days later, thickening of the cornea, with 2+ to 3+ corneal edema and bullac, was still present. Examination revealed an adherent fibrous mass in the inferior nasal sector, with prominent keratic precipitates on the endothelial surface. The patient was readmitted 18 days following discharge. At that time, a pigment band above the limbus, first noted two weeks earlier, had become more strikingly delineated. The anterior chamber was shallower, with obliteration of the superior pole. Ultrasound examination revealed thickening of the choroid. Ten days following admission, the patient underwent removal of the cataract and the remaining fibrous material on the anterior surface of the iris. Two days later
microcystic edema of the entire cornea and
folds in Descemet's membrane were noted. The anterior chamber was of good depth. The retina was normal. The visual acuity
sphere. Postoperatively secondary glaucoma developed that ultimately required cyclocyrowas 20/400 with a +12.50
therapy for control of the elevated intraoc-
ular pressure. Vision gradually deteriorated. On Peb 13, 1976, more than seven months after the onset of illness, the
intraocular pressure was 6 mm and the patient had no pain in the eye. Vision in
the right eye was limited to appreciation of hand motion only; there was microcystic corneal edema, stromal and the vitreous face
nized.
neovascularization, was totally orga-
cleosis,12 pericarditis," and brain abscess." Listeria infections of the eye
in the form of conjuncand tivitis" congenital listeriosis with ocular involvement.1" Listeria endophthalmitis has been reported only once
usually
occur
previously."
commonly, bacterial endophthalmitis is caused by Staph aureus," Most
Staph epidermidis,'"
sp,'" and Proteus sp.'" Less frequently,
Serratia marcescens,-" Escherichia
coli," Streptococcus pneumoniae,"
Neisseria catarrhalis," and Clostrid-
perfringens"3 are responsible. Although the majority of cases of
ium
bacterial
COMMENT
to
Listeria monocytogenes is a pleomorphic Gram-positive bacillus that has produced a wide variety of infections in humans, including meningitis," dermatitis,7 amnionitis," subacute
bacterial endocarditis," cholecystitis," bacteremia,8 habitual abortion,'" Wound infection," infectious mononu-
Pseudomonas
endophthalmitis
are
related
surgical procedures or to local
trau-
ma,-'-'1 endophthalmitis may be a manifestation of bacteremia emanatfrom a distant focus of infection."1"' In our patient it would appear most likely that minor eye trauma was associated with the introduction of L monocytogenes, since this microorganism is widely distributed in
ing
nature and has been found in a large variety of mammals and fowl. A variety of antimicrobial agents have been successfully utilized in
Listeria infections. These include
am-
picillin, penicillin G, tetracycline, chloramphenicol, erythromycin, streptomycin, and the sulfonamides.-'7 It -"
has been demonstrated that there is synergistic killing of Listeria in vitro when ampicillin is combined with an aminoglycoside antibiotic such as gentamicin.-" Since intraocular penetration of ampicillin is satisfactory at standard doses,3" it would appear to be the antibiotic of first choice for treatment of endophthalmitis caused by L
numocytogenes. In
conclusion, this
strates that L
case
demon-
monocytogenes may be
important ocular pathogen. Since organism is so widespread in nature, awareness of its ocular pathogenicity may lead to diagnosis and appropriate therapy of additional
an
the
cases
in the future.
References 1. Louria DB, Hensel T, Armstrong D, et al: Listeriosis complicating malignant disease: A new association. Ann Intern Med 67:261-281, 1967. 2. Buchner LH, Schneierson SS: Clinical and laboratory aspects of Listeria monocytogenes
infections.
Am J Med 45:904-920, 1968. 3. Gantz NM, Myerowitz RL, Medeiros AA, et al: Listeriosis in immunosuppressed patients. Am Med 58:637-643, 1975. 4. Maguire GJ, Riley JH Jr: Infections due to Listeria monocytogenes in infants and children. Am J Med Sci 58:421-428, 1967. 5. Gavan TL: Bacteriology, in Faulkner WR, King JW (eds): Manual of Clinical Laboratory Procedures, ed 2. Cleveland, Ohio, Chemical Rubber, 1970, pp 249-311. 6. Dedrick JW: Listeria meningitis: A report of eight cases. Am J Med Sci 233:617-621, 1957. 7. Owen CR, Meis A, Jackson JW, et al: A case of primary cutaneous listeriosis. N Engl J Med 262:1026-1028, 1960. 8. Medoff G, Meis A, Jackson JW, et al: Listeriosis in humans: An evaluation. Infect Dis 123:247-250, 1971. 9. Hoeprich PD, Chernoff HM: Subacute bacterial endocarditis due to Listeria monocytogenes. Am J Med 19:488-494, 1955. 10. Rappaport F, Rabinovitz M, Taoff R, et al: Genital listeriosis as a cause of repeated abortion. J
J
Lancet 1:1273-1275, 1960. 11. Torregosa M: Infrequently encountered infections with gram-positive bacilli. Am J Clin Pathol 50:689-691, 1968. 12. Gray ML, Killinger AH: Listeria monocytogenes and Listeria infections. Bacteriol Rev 30:309-382, 1966. 13. Ashfaque K, Rosen MR, Rahimtoola SH, et al: Listeria bacteremia with acute pericarditis. Chest 60:496-497, 1971. 14. Halkin H, Shacked IJ, Altman G: Brain abscess due to Listeria monocytogenes in a patient with cirrhosis of the liver, Isr J Med Sci 7:1192-1195, 1971. 15. Felsenfeld O: Diseases of poultry transmissible to man. Iowa State Coll Vet 13:89-92, 1951. 16. Manschot WA: Congenital listeriosis with ocular involvement. Ophthalmologica 162:167-172, 1971. 17. Goodner EK, Okumoto M: Introcular listeriosis. Am J Ophthalmol 64:682-686, 1967. 18. Allen HF, Mangiaracine AB: Bacterial endophthalmitis after cataract extraction. Arch Ophthalmol 91:3-7, 1974. 19. Valenton MD, Brubaker RF, Allen HF:
Staphylococcus epidermidis endophthalmitis. Arch Ophthalmol 89:94-96, 1973. 20. Salceda SR,
marcescens
Japuz J, Vizconde
endophthalmitis.
89:163-166, 1973.
Arch
R: Serratia
Ophthalmol
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/13/2015
21. Allen HF, Mangiaracine AB: Bacterial endophthalmitis after cataract extraction. Arch Ophthalmol 72:454-462, 1973. 22. Girmer I: Neisseria catarrhalis endophthalmitis. Am J Ophthalmol 32:699-702, 1949. 23. Kunz GH, Weiss JF: Gas gangrene panophthalmitis. Br J Ophthalmol 53:323-326, 1969. 24. Christy NE, Lall P: Postoperative endophthalmitis following cataract surgery. Arch Ophthalmol 90:361-366, 1973. 25. Jain MR, Sharma HR: Puerperal sepsis leading to bilateral fulminating purulent endoph-
thalmitis with tenonitis. Br J Ophthalmol 57:698\x=req-\ 699, 1973. 26. Dreyer NP, Fields BN: Heroin-associated infective endocarditis. Ann Intern Med 78:699\x=req-\
702, 1973.
27. Seeliger HRR: Listeriosis. New York, Hafner Publishing Co, 1961. 28. Jorden RD, Barrett FF, Yow MD: Ampicillin treatment of listeriosis. J Pediatr 77:1067\x=req-\ 1070, 1970. 29. Moellering RC Jr, Medoff G, Leech I, et al: Antibiotic synergism against Listeria monocytogenes. Antimicrob Agents Chemother 1:30-34, 1972. 30. Recorder RE, Ellis PP: The intraocular penetration of ampicillin, methicillin, and oxacillin. Am J Ophthalmol 64:135-143, 1967.
Endophthalmitis
Adolfo G. Bagnarello, MD; Allison J. Berlin, MD; Allan J. Weinstein, MD; Martin C. McHenry, MD; Patrick S. O'Connor, MD
\s=b\ Listeria
monocytogenes and
phylococcus organism caused
a a
strophic endophthalmitis in a patient despite appropriate local and systemic antimicrobial chemotherapy. Although L monocytogenes is widespread in nature and has produced a variety of clinical illnesses, It has only once previously been reported to cause endophthalmitis. If appropriate microbiologic techniques are not employed, the organism may go unrecognized as an ocular pathogen. (Arch Ophthalmol 95:1004-1005, 1977)
Infections
due to Listeria monocytogenes have been described with
increasing frequency
in
recent
years.'3 While Listeria infections in newborn children have long been
recognized/ the organism has only rarely been appreciated to be a pathogen in adults in whom host
defense mechanisms have not been altered, either by malignancy or immunosuppressive therapy. It is the purpose of the present report to describe a patient with apparently normal host defenses in whom L
monocytogenes played
important pathogenesis of endophthalmitis. To our knowledge, this is an
role in the
the second case in which L monocytogenes has been responsible for endophthalmitis, either alone or in concert with other ocular pathogens.
publication Sept 24, 1976. From the Departments of Infectious Disease (Drs Bagnarello, Weinstein, and McHenry) and Ophthalmology (Drs Berlin and O'Connor), Cleveland Clinic Foundation, Cleveland. Reprints not available.
Accepted
for
REPORT OF A CASE
stacata-
A 68-year-old farmer developed redness, photophobia, and pain in the right eye
during the last week of June 1975. Despite topical and systemic antimicrobial chemotherapy and anti-inflammatory therapy, the patient's symptoms progressed; on July 22, 1975, he was referred to the Cleveland Clinic Hospital for further evaluation.
The blood pressure was 170/95 mm Hg, the pulse rate was 76 beats per minute, the respiratory rate was 12/min, and the temperature was 36.5 C, orally. Findings from a complete physical examination were within normal limits except for the right eye. Visual acuity in the right eye was limited to light perception only, the conjunctiva was hyperemic, and there was marked chemosis. A large central epithelial abrasion of the cornea was associated with marked (4 + ) epithelial edema, central horizontal striae, and large keratic precipitates on the posterior surface. The anterior chamber was almost completely occluded by a dense hypopyon. The iris was widely dilated, and details of the iris were visible only at the superior pole of the eye. The posterior segment was not visible. The intraocular pressure in the right eye was 68 mm.
Results of initial laboratory studies, including hemoglobin, leukocyte count, and tests of renal and hepatic function, were
normal. Blood cultures were sterile. The blood glucose level was 288 mg/100 ml at two hours during a standard glucose tolerance
test.
Under aseptic technique, a paracentesis of the anterior chamber of the right eye was performed. Gram-stain of the turbid fluid demonstrated numerous polymorpho-
nuclear leukocytes, Gram-positive bacilli, and Gram-positive cocci. Cultures of this fluid yielded L monocytogenes and St.aphylococcux epidermidis. Identification of S epiderm.id.is was performed according to routine bactériologie criteria.1 Listeria
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/13/2015
monocytogenes was identified on the basis of the following observations: the organism was a pleomorphic Gram-positive bacillus that produced /)-hcmolysis on sheep blood agar. It was motile at 37 C and at room temperature, but not at 40 C. The catalase reaction was positive, while the oxidase reaction was negative. The organism fermented glucose, maltose, trehalose, and salicin, but failed to ferment sucrose, lactose, dulcitol, and mannitol. The minimal inhibitory concentration of ampicillin for this organism was less than 0.1
ug/ml.
patient was treated with ampicillin, intravenously every 4 hours for 18 days, methicillin, 2 mg intravenously every 4 hours for 14 days, gentamicin, 100 mg intravenously every 8 hours for 5 days, and sub-Tenon's methicillin, 100 mg daily for 7 days. In addition, topical dexamethasone and atropine were administered. The patient was discharged from the hospital The
2 gm
when there was apparent resolution of the hypopyon of the anterior chamber. However, the visual acuity in the right eye was limited to light perception only. On discharge from the hospital, the patient was placed on a regimen of oral ampicillin and topical gentamicin. Eleven days later, thickening of the cornea, with 2+ to 3+ corneal edema and bullac, was still present. Examination revealed an adherent fibrous mass in the inferior nasal sector, with prominent keratic precipitates on the endothelial surface. The patient was readmitted 18 days following discharge. At that time, a pigment band above the limbus, first noted two weeks earlier, had become more strikingly delineated. The anterior chamber was shallower, with obliteration of the superior pole. Ultrasound examination revealed thickening of the choroid. Ten days following admission, the patient underwent removal of the cataract and the remaining fibrous material on the anterior surface of the iris. Two days later
microcystic edema of the entire cornea and
folds in Descemet's membrane were noted. The anterior chamber was of good depth. The retina was normal. The visual acuity
sphere. Postoperatively secondary glaucoma developed that ultimately required cyclocyrowas 20/400 with a +12.50
therapy for control of the elevated intraoc-
ular pressure. Vision gradually deteriorated. On Peb 13, 1976, more than seven months after the onset of illness, the
intraocular pressure was 6 mm and the patient had no pain in the eye. Vision in
the right eye was limited to appreciation of hand motion only; there was microcystic corneal edema, stromal and the vitreous face
nized.
neovascularization, was totally orga-
cleosis,12 pericarditis," and brain abscess." Listeria infections of the eye
in the form of conjuncand tivitis" congenital listeriosis with ocular involvement.1" Listeria endophthalmitis has been reported only once
usually
occur
previously."
commonly, bacterial endophthalmitis is caused by Staph aureus," Most
Staph epidermidis,'"
sp,'" and Proteus sp.'" Less frequently,
Serratia marcescens,-" Escherichia
coli," Streptococcus pneumoniae,"
Neisseria catarrhalis," and Clostrid-
perfringens"3 are responsible. Although the majority of cases of
ium
bacterial
COMMENT
to
Listeria monocytogenes is a pleomorphic Gram-positive bacillus that has produced a wide variety of infections in humans, including meningitis," dermatitis,7 amnionitis," subacute
bacterial endocarditis," cholecystitis," bacteremia,8 habitual abortion,'" Wound infection," infectious mononu-
Pseudomonas
endophthalmitis
are
related
surgical procedures or to local
trau-
ma,-'-'1 endophthalmitis may be a manifestation of bacteremia emanatfrom a distant focus of infection."1"' In our patient it would appear most likely that minor eye trauma was associated with the introduction of L monocytogenes, since this microorganism is widely distributed in
ing
nature and has been found in a large variety of mammals and fowl. A variety of antimicrobial agents have been successfully utilized in
Listeria infections. These include
am-
picillin, penicillin G, tetracycline, chloramphenicol, erythromycin, streptomycin, and the sulfonamides.-'7 It -"
has been demonstrated that there is synergistic killing of Listeria in vitro when ampicillin is combined with an aminoglycoside antibiotic such as gentamicin.-" Since intraocular penetration of ampicillin is satisfactory at standard doses,3" it would appear to be the antibiotic of first choice for treatment of endophthalmitis caused by L
numocytogenes. In
conclusion, this
strates that L
case
demon-
monocytogenes may be
important ocular pathogen. Since organism is so widespread in nature, awareness of its ocular pathogenicity may lead to diagnosis and appropriate therapy of additional
an
the
cases
in the future.
References 1. Louria DB, Hensel T, Armstrong D, et al: Listeriosis complicating malignant disease: A new association. Ann Intern Med 67:261-281, 1967. 2. Buchner LH, Schneierson SS: Clinical and laboratory aspects of Listeria monocytogenes
infections.
Am J Med 45:904-920, 1968. 3. Gantz NM, Myerowitz RL, Medeiros AA, et al: Listeriosis in immunosuppressed patients. Am Med 58:637-643, 1975. 4. Maguire GJ, Riley JH Jr: Infections due to Listeria monocytogenes in infants and children. Am J Med Sci 58:421-428, 1967. 5. Gavan TL: Bacteriology, in Faulkner WR, King JW (eds): Manual of Clinical Laboratory Procedures, ed 2. Cleveland, Ohio, Chemical Rubber, 1970, pp 249-311. 6. Dedrick JW: Listeria meningitis: A report of eight cases. Am J Med Sci 233:617-621, 1957. 7. Owen CR, Meis A, Jackson JW, et al: A case of primary cutaneous listeriosis. N Engl J Med 262:1026-1028, 1960. 8. Medoff G, Meis A, Jackson JW, et al: Listeriosis in humans: An evaluation. Infect Dis 123:247-250, 1971. 9. Hoeprich PD, Chernoff HM: Subacute bacterial endocarditis due to Listeria monocytogenes. Am J Med 19:488-494, 1955. 10. Rappaport F, Rabinovitz M, Taoff R, et al: Genital listeriosis as a cause of repeated abortion. J
J
Lancet 1:1273-1275, 1960. 11. Torregosa M: Infrequently encountered infections with gram-positive bacilli. Am J Clin Pathol 50:689-691, 1968. 12. Gray ML, Killinger AH: Listeria monocytogenes and Listeria infections. Bacteriol Rev 30:309-382, 1966. 13. Ashfaque K, Rosen MR, Rahimtoola SH, et al: Listeria bacteremia with acute pericarditis. Chest 60:496-497, 1971. 14. Halkin H, Shacked IJ, Altman G: Brain abscess due to Listeria monocytogenes in a patient with cirrhosis of the liver, Isr J Med Sci 7:1192-1195, 1971. 15. Felsenfeld O: Diseases of poultry transmissible to man. Iowa State Coll Vet 13:89-92, 1951. 16. Manschot WA: Congenital listeriosis with ocular involvement. Ophthalmologica 162:167-172, 1971. 17. Goodner EK, Okumoto M: Introcular listeriosis. Am J Ophthalmol 64:682-686, 1967. 18. Allen HF, Mangiaracine AB: Bacterial endophthalmitis after cataract extraction. Arch Ophthalmol 91:3-7, 1974. 19. Valenton MD, Brubaker RF, Allen HF:
Staphylococcus epidermidis endophthalmitis. Arch Ophthalmol 89:94-96, 1973. 20. Salceda SR,
marcescens
Japuz J, Vizconde
endophthalmitis.
89:163-166, 1973.
Arch
R: Serratia
Ophthalmol
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/13/2015
21. Allen HF, Mangiaracine AB: Bacterial endophthalmitis after cataract extraction. Arch Ophthalmol 72:454-462, 1973. 22. Girmer I: Neisseria catarrhalis endophthalmitis. Am J Ophthalmol 32:699-702, 1949. 23. Kunz GH, Weiss JF: Gas gangrene panophthalmitis. Br J Ophthalmol 53:323-326, 1969. 24. Christy NE, Lall P: Postoperative endophthalmitis following cataract surgery. Arch Ophthalmol 90:361-366, 1973. 25. Jain MR, Sharma HR: Puerperal sepsis leading to bilateral fulminating purulent endoph-
thalmitis with tenonitis. Br J Ophthalmol 57:698\x=req-\ 699, 1973. 26. Dreyer NP, Fields BN: Heroin-associated infective endocarditis. Ann Intern Med 78:699\x=req-\
702, 1973.
27. Seeliger HRR: Listeriosis. New York, Hafner Publishing Co, 1961. 28. Jorden RD, Barrett FF, Yow MD: Ampicillin treatment of listeriosis. J Pediatr 77:1067\x=req-\ 1070, 1970. 29. Moellering RC Jr, Medoff G, Leech I, et al: Antibiotic synergism against Listeria monocytogenes. Antimicrob Agents Chemother 1:30-34, 1972. 30. Recorder RE, Ellis PP: The intraocular penetration of ampicillin, methicillin, and oxacillin. Am J Ophthalmol 64:135-143, 1967.
