Torulopsis glabrata Endophthalmitis After Keratoplasty With an Organ-Cultured Cornea Peter A. Larsen MD; Richard L. Lindstrom, MD; Donald J.
Doughman, MD
encountered postoperatively. We have found no previous reports in the literature of fungal endophthalmitis
endophthalmitis developed in elderly woman following penetrating keratoplasty with an organ-cultured cor-
was
nea. An unsuccessful search was made for the source of the infection. Modification in our sterility checks prior to surgery were made in hopes of preventing future infections.
following penetrating keratoplasty
\s=b\ Fungal
an
(Arch Ophthalmol 96:1019-1022, 1978)
of organ-cultured Thefor penetrating keratoplasty use
corneas
at
the University of Minnesota began on Jan 18, 1974. At first, this was done only in poor prognosis cases and was subsequently extended to all patients in October based on favorable experi¬ ence in the bad prognosis cases.'2 As of Aug 16, 1976, 132 eyes had been grafted with organ-cultured corneas from our institution. We present here a patient in whom Torulopsis glabrata endophthalmitis developed after pen¬ etrating keratoplasty with organcultured cornea, which is the only case of fungal infection in our series that Accepted
for publication Aug 20, 1977. From the Department of Ophthalmology, University of Minnesota, Minneapolis. Reprint requests to Box 493, Mayo Memorial Bldg, University of Minnesota, Minneapolis, MN 55455.
with either fresh tissue or organcultured corneas, although fungal con¬ tamination of donor eyes and fungal corneal infections after lamellar kera¬ toplasty have been reported.' Le Francois and Baum have recently reported Flavobacterium endophthal¬ mitis after penetrating keratoplasty in which the donor button was stored in McCarey-Kaufman (M-K) tissuecultured medium.4 Shaw and Aquavella have recently reported two cases of pneumococcal endophthalmitis follow¬ ing fresh tissue penetrating kerato¬ plasty that resulted in phthisis and enucleation."' REPORT OF A CASE A
76-year-old
white
woman
with adult-
onset diabetes, bilateral
aphakia, and bilat¬ eral bullous keratopathy was first seen in our Eye Clinic on April 20, 1976. She had undergone intracapsular cataract extrac¬ tion in the right eye in 1957 and enjoyed 20/20 vision until 1967, when she had grad¬ ually decreasing visual acuity because of corneal edema that progressed to bullous keratopathy. She had cataract surgery in
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
However, because of possible optic atrophy and the development of a pupillary membrane and bullous kera¬ topathy, the patient never had good vision postoperatively. The best corrected visual acuity when she was first seen was 20/400 in the right eye and counts fingers at two the left eye in 1959.
feet in the left eye. The patient was scheduled for pene¬ trating keratoplasty in the right eye and this was performed by two of us (D. J. D. and R. L. L.) on May 26, 1976 with an organ-cultured cornea. A 7.5-mm recipient site was prepared, a partial anterior vitrec¬ tomy was performed, and an 8-mm donor button was sutured in place with running 10-0 nylon. The procedure went smoothly and without complications. The donor cornea was organ-cultured at 37 C, as described in earlier papers.'-- The donor cornea was harvested from a 31year-old man, a victim of an automobile accident, whose respiration was assisted mechanically and who had a flat EEG. The eyes were removed aseptically by one of us (P. A. L.) in the operating room at the same time the kidneys were being harvested by the transplant surgeons. Grossly, the eyes appeared to be in perfect condition. Vital signs of the donor had been well main¬ tained prior to harvest of the globes. The globe was flooded with a mixture of poly¬ myxin B sulfate, neomycin sulfate, and gramicidin (Neosporin) and stored at 4 C
Antifungal Sensitivities Torulopsis glabrata* MIC.
Amphotericin Natamycin Flucytosine Clotrimazole Miconazole Econazole
of
MCC,
fig/ml
/xg/ml
0.50 8.00 0.25 8.00 0.25 0.25
4.0 32.0 0.5 32.0 2.0 1.0
"MIC indicates minimal inhibitory concentra¬
tion; MCC, minimal cidal concentration.
added to the M-K media. Serum was not added. At this last media change, old and new media were streaked onto blood agar and Sabouraud's plates and cultured at 37 C and at room temperature to check steril¬ ity. Any growth on culture or turbidity of the M-K media causes the corneal button to be discarded and another cornea is selected that has been similarly quarantined. Post¬ operatively, the M-K media and the donor corneal rim are frozen for further investi¬
Fig
1 —Round white
mass
appearing
on
endothelial surface.
gation.
The graft did not clear well postopera¬ tively and had a pachometry reading of .78
June 1. Some vitreous haze was noted and prednisone therapy, 60 mg/day, was started on June 2 and tapered to 20 mg/ day, with some improvement by the time the patient was discharged on June 8. The patient also received topical 0.1% dexa¬ methasone every four hours while awake, 1.0% atropine sulfate twice daily, genta¬ micin sulfate drops twice daily, and 2.5% cellulose gum every four hours while she was awake. The patient continued to receive lowdose oral prednisone until July 13, at which time the patient had +1- + 2 flare, persis¬ tent graft edema, and a small white mass on the posterior cornea near the wound at the 12-o'clock position (Fig 1). The patient was rehospitalized for vigor¬ ous treatment of the suspected rejection episode. By the time she was discharged on June 20, the pachometry reading was .60 and the cornea was slightly clear, but the white mass at the 12-o'clock position was no smaller. On Aug 5, the mass at the 12-o'clock position was slightly larger. The patient continued to worsen and was rehospitalized on Aug 21. At this time a smaller white mass at the 11-o'clock position on the poste¬ rior cornea was first noted, as well as increasing vitreous haze. It was suspected that this was a stitch abscess and sutures were removed on Aug 22 without problems. The patient did not improve, and on Aug 25 an anterior chamber and vitreous tap were performed and the white mass at the 12o'clock position was partially excised on
Fig 2.—Luxuriant growth of Torulopsis glabrata from thawed storage media (left) and scierai rim (right) 24 hours after inoculation onto Sabouraud's plates. for a few hours prior to processing for organ culture. The cornea was removed from the globe with a 3-mm rim of sclera and placed epithelial side down in a dispos¬ able plastic Petri dish that contained 15 mm of minimal essential medium (MED). (The compositions of the organ culture media were as follows: MEM [Eagle's] with Earle's salts without L-glutamine, 500 ml; decomplemented calf or recipient serum, 50 ml; L-glutamine, 5 ml; penicillin, 100 units/ ml; streptomycin, 100 units/ml; amphoter¬ icin B, 0.25 µg/ml.) The dish was placed in a water-jacketed tissue culture incubator and maintained at 37 C in an atmosphere
air, 5% carbon dioxide, and 100% humidity. The MEM was changed three times weekly. All procedures were done with a sterile technique in a laminar flow hood. In our organ culture laboratory, any of 95%
contaminated cultures (turbid MEM) are discarded as soon as they are recognized. At surgery, if any turbidity is noted, the cornea is not used. At the time of this graft, we were placing the corneas in M-K media at 27 C for the last 48 hours preoperatively in order to obtain thin donor material. Penicillin, streptomycin, and amphotericin in the concentrations previously stated were
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through
the keratoplasty wound. Smears from the white mass showed a budding yeast and vitreous cultures were 4+ posi¬ tive within 24 hours for glabrata, a Candida-like yeast of low pathogenicity whose hosts are usually diabetic and immu-
nosuppressed.""'
We retrieved and thawed the donor corneal rim and fluid. Both were cultured on Sabouraud's media and produced a luxu¬ riant growth of Torulopsis overnight
(Fig 2). Following current recommendations,"'5 treatment was started immediately with intravenously (IV) injected amphotericin B, oral flucytosine (2.5 gm four times a day), topical 1% flucytosine (one drop every four hours), and topical 0.5% amphotericin B. The latter was stopped shortly there¬ after because of local irritation. The IV amphotericin was started at 5 mg/day and by 5-mg daily increments, the patient reached 50 mg/day, at which point the 50mg dosage was given on an every-otherday schedule. Prednisone was tapered to 10 mg/day. A sample of the organism was sent to Daniel B.
Jones, MD, in Houston, who performed sensitivity tests (Table). On this regimen, the vitreous haze cleared,
cleared slowly, and the white the posterior cornea diminished until it was no longer visible on Sept 11 (Fig 3). The patient's urine and stool were cultured and no Torulopsis was found. Laboratory personnel who were involved with the organ culture and the two surgeons who performed the transplant were all found to be culture negative for glabrata on swabs from the nose, mouth, axilla, and groin. The floor and working counter in the organ culture room produced no Torulopsis on culture. was given until an Amphotericin accumulative IV dose of 475 mg was received, but this was discontinued on Sept 12, when lethargy, diarrhea, and nausea developed. Flucytosine was discontinued on Sept 14. At no time did the patient's creatinine level exceed 2.4 mg/100 ml, nor did the BUN level rise above 48 mg/100 ml. After the amphotericin and flucytosine were discontinued, the creatinine and BUN levels fell rapidly to pretreatment levels; they were 1.1 mg/100 ml and 13 mg/100 ml, respectively, on Sept 19 and remained near these values. In spite of normalization of renal function, the patient continued to have unrelenting nausea, lethargy, and diarrhea. Intravenous fluids were neces¬ sary to maintain hydration. Consults were obtained from the Infectious Disease, Endocrine, and Gastrointestinal Services, but no cause for the patient's systemic illness other than recent antifungal thera¬ py could be found. the
cornea
mass on
Fig
3.—White
On Sept 27, amphotericin no recurrence
mass on
endothelial surface
was no
12 days after cessation of and flucytosine, there was of the corneal deposits or
patient was transferred on Sept 27, after an episode of unresponsiveness with a blood glucose of 28 mg/100 ml that was treated with IV push D5„W· The patient sustained a cardiac arrest on the morning of Sept 28 and efforts at resuscitation were unsuccessful. Autopsy and eye removal requests were denied by the patient's family. vitreous haze. The
to the Endocrine Service
COMMENT
Torulopsis glabrata is an ovoid, slightly elongated yeast-like fungi that measures 2 to 3 µ by 3 to 4 µ. It fails to produce hyphae in tissues or culture and lacks a true capsule.'" Torulopsis glabrata was first isolated from human stool by Anderson10 in 1917 and named Cryptococcus glabra¬ ta. Lodder and de Vries introduced the
"Torulopsis glabrata" in 1937.7 In current taxonomy, glabrata is in the order Cryptococcales of asporogenous yeasts. This order contains a single family, Crytococcaceae, includ¬ ing mycelial and nonmycelial forms. A new subfamily, cryptococcideae, in¬ cludes the genera Candida, Torulop¬ sis, and Cryptococcus. Various reports in the literature state that glabrata causes such infections as fungemia, renal and urinary tract infections, and name
endocarditis.818"1"
Torulopsis glabrata
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
longer
visible
on
Sept 11, 1976.
has been isolated from the conjunc¬
tivas of normal adult eyes and has been implicated in lacrimal canal infections.2" Torulopsis gfabrata is apparently not a common inhabitant of the conjunctiva, however, as evi¬ denced by results of numerous studies of eye flora in which the organism has not been found.2123 To our knowledge, glabrata has not previously been implicated as an organism that is responsible for endophthalmitis. Most of the reports of infections involving glabrata were in patients who were generally debilitated, dia¬ betic, previously treated with antibi¬ otics, or immunosuppressed. Our pa¬ tient was an elderly diabetic woman who had been treated with rather large doses of oral steroids prior to the recognition of the glabrata endoph¬ thalmitis. We have no explanation why the Torulopsis grew well in less than 24 hours from the frozen rim and media postoperatively on a Sabouraud's plate, whereas the preoperative cul¬ tures were negative. Possible explana¬ tions are: (1) The organism was intro¬ duced from an operating room source, which contaminated both the donor cornea and rim; (2) The patient carried the organism; or (3) The orga¬ nism was present in the donor cornea and media preoperatively and was missed by the sterility checks we
employed
at the time of surgery.
In close
cooperation with the microbiologists we have modified our tech¬ nique of incubation and sterility checks in hopes of eliminating the possibility of any contamination of donor material going undetected. We have removed penicillin, streptomy¬ cin, and amphotericin from the last two media changes to allow any micro¬ organism to manifest itself prior to transplant and to eliminate the possi¬ bility of residual antimicrobials giv¬ ing false negative culture results. For its final media change, the cornea is placed in 60 mm of MEM in a large, sealed tube five to seven days prior to transplant. A larger volume is used to ensure adequate substrate for the survival of donor material. Ten milli¬ meter aliquots are taken from the last and next to the last media changes five to seven days prior to transplant and are sent to the main hospital Microbiology Department for aerobic, anaerobic, and fungal cultures at room temperature and at 37 C in enrich¬ ment broth. Although the endophthalmitis cleared on the regimen of IV, oral, and topical medications, it is interesting to speculate whether the lengthy hospi¬ tal stay and the eventual fatal outcome could have been altered by having used intraocular amphotericin with or without vitrectomy, as described by Peyman and Sanders21 and Forster et al.25 We also have no way of knowing whether the patient's own defenses may have eliminated the organism without treatment had steroids been withdrawn as soon as the infection with this low-virulence organism
was
recognized.
A four-month moratorium on or¬ gan-cultured corneas for transplant
observed after the discovery of the fungal endophthalmitis. No other infection occurred in our other trans¬ plant patients. Penetrating kerato¬ plasty with organ-cultured corneas was reinstated using our modified sterility checks in December 1976 and has continued to the present time at our institution without any evidence of infections. We do not know what role, if any, the organ-cultured cornea played in producing the endophthalmitis. Hope¬ fully, our modification of the organculture protocol will ensure against introduction of potential ocular path¬ ogens via donor material. was
Daniel B. Jones, MD, Houston, performed sensitivity studies on the organism.
the
Key Words.— Torulopsis glabrata; pene¬ trating keratoplasty; endophthalmitis; or¬ gan culture.
Names and Trademarks of Drugs
Nonproprietary
Amphotericin B—Fungizone. Flucytosine-A wcoòom. Gentamicin sulfate- Gara my ein. References 1. Doughman DJ, Harris JE, Schmidt MK: Penetrating keratoplasty using 37\s=deg\C. organ cultured corneas. Trans Am Acad Ophthalmol Otolaryngol 81:778-793, 1976. 2. Doughman DJ, Harris JE, Lindstrom RL, et al: Corneal preservation using 37\s=deg\organ culture incubation, in Lemp MA, King JH Jr (eds): Second World Congress on the Cornea, Boston, Little Brown & Co, to be published. 3. White JH: Fungal contamination of donor eyes. Br J Ophthalmol 53:30-33, 1969. 4. Le Francois M, Baum JL: Flavobacterium endophthalmitis following keratoplasty: Use of a tissue culture medium-stored cornea. Arch Ophthalmol 94:1907-1909, 1976. 5. Shaw EL, Aquavella JU: Pneumococcal endophthalmitis following grafting of corneal tissue from a (cadavor) kidney donor. Ann Ophthalmol 9:435-440, 1977. 6. Hasenclever HF, Mitchell WO: Pathogenesis
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
of Torulopsis glabrata in physiologically altered mice. Sabouraudia 2:87-95, 1962. 7. Lodder J, de Vries NF: Some notes on Torulopsis glabrata (Anderson) nov comb. Mycopathologia 1:98-103, 1938. 8. Marks MI, Langston C, Eickhoff TC: Torulopsis glabrata: An opportunistic pathogen in man. N Engl J Med 283:1131-1135, 1970. 9. Pankey GA, Daloviso JR: Fugemia caused by Torulopsis glabrata. Medicine 52:395-403, 1973. 10. Anderson HW: Yeast-like fungi of the human intestinal tract. J Infect Dis 21:341-386, 1917. 11. Lieberman TW: Systemic antifungal chemotherapy in treatment of intraocular fungal infection, in Leopold IH (ed): Symposium Ocular Therapy. St Louis, CV Mosby Co Publishers, 1973, vol 6, pp 59-73. 12. Bennett JE: Chemotherapy of systemic mycosis, (first of two parts). N Engl J Med 290:30-31, 1974. 13. Bennett JE: Chemotherapy of systemic mycosis (second of two parts). (Part II), N Engl J Med 290:320-322, 1974. 14. Jones BR: Principles in the management of oculomycosis. Am J Ophthalmol 79:719-751, 1975. 15. Harder EJ, Hermans PE: Treatment of fungal infections with flu cytosine. Arch Intern Med 135:231-237, 1975. 16. Grimley PM, Wright LD, Jennings AE: Torulopsis glabrata infection in man. Am J Clin Pathol 43:216-223, 1965. 17. Kauffman CA, Tan JS: Torulopsis glabrata, renal infection. Am J Med 57:217-224, 1974. 18. Sharpe DN, Singh BM, Cornere BM, et al: Torulopsis glabrata endocarditis complicating aortic hemograft valve treated with 5-Fluorocytosine. N Z Med J 81:294-298, 1975. 19. Haley LD: Yeast of medical importance. Am J Clin Pathol 36:227-234, 1961. 20. Locatchar-Khorazo D, Seegal BC: Microbiology of the Eye. St Louis, CV Mosby Co Publishers, 1972, pp 208-240. 21. Tomar VPS, Sharma OP, Joshi K: Bacterial and fungal fluora of normal conjunctiva. Ann Ophthalmol 3:669-671, 1971. 22. Williamson J, Gordon AM, et al: Fungal flora of the conjunctival sac in health and disease. Br J Ophthalmol 52:127-137, 1968. 23. Polack FM, Locatcher-Khorazo D, Gutierrez E: Bacteriologic study of "donor" eyes: Evaluation of antibacterial treatments prior to corneal grafting. Arch Ophthalmol 78:219, 1967. 24. Peyman GA, Sanders DR: Advances in Uveal Surgery, Vitreous Surgery, and the Treatment of Endophthalmitis. New York, Appleton\x=req-\ Century-Crofts, 1975, pp 179-228. 25. Forster RK, Zachary IG, et al: Further observations on the diagnosis, cause, and treatment of endophthalmitis. Am J Ophthalmol 81:52\x=req-\ 56, 1976.
Doughman, MD
encountered postoperatively. We have found no previous reports in the literature of fungal endophthalmitis
endophthalmitis developed in elderly woman following penetrating keratoplasty with an organ-cultured cor-
was
nea. An unsuccessful search was made for the source of the infection. Modification in our sterility checks prior to surgery were made in hopes of preventing future infections.
following penetrating keratoplasty
\s=b\ Fungal
an
(Arch Ophthalmol 96:1019-1022, 1978)
of organ-cultured Thefor penetrating keratoplasty use
corneas
at
the University of Minnesota began on Jan 18, 1974. At first, this was done only in poor prognosis cases and was subsequently extended to all patients in October based on favorable experi¬ ence in the bad prognosis cases.'2 As of Aug 16, 1976, 132 eyes had been grafted with organ-cultured corneas from our institution. We present here a patient in whom Torulopsis glabrata endophthalmitis developed after pen¬ etrating keratoplasty with organcultured cornea, which is the only case of fungal infection in our series that Accepted
for publication Aug 20, 1977. From the Department of Ophthalmology, University of Minnesota, Minneapolis. Reprint requests to Box 493, Mayo Memorial Bldg, University of Minnesota, Minneapolis, MN 55455.
with either fresh tissue or organcultured corneas, although fungal con¬ tamination of donor eyes and fungal corneal infections after lamellar kera¬ toplasty have been reported.' Le Francois and Baum have recently reported Flavobacterium endophthal¬ mitis after penetrating keratoplasty in which the donor button was stored in McCarey-Kaufman (M-K) tissuecultured medium.4 Shaw and Aquavella have recently reported two cases of pneumococcal endophthalmitis follow¬ ing fresh tissue penetrating kerato¬ plasty that resulted in phthisis and enucleation."' REPORT OF A CASE A
76-year-old
white
woman
with adult-
onset diabetes, bilateral
aphakia, and bilat¬ eral bullous keratopathy was first seen in our Eye Clinic on April 20, 1976. She had undergone intracapsular cataract extrac¬ tion in the right eye in 1957 and enjoyed 20/20 vision until 1967, when she had grad¬ ually decreasing visual acuity because of corneal edema that progressed to bullous keratopathy. She had cataract surgery in
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
However, because of possible optic atrophy and the development of a pupillary membrane and bullous kera¬ topathy, the patient never had good vision postoperatively. The best corrected visual acuity when she was first seen was 20/400 in the right eye and counts fingers at two the left eye in 1959.
feet in the left eye. The patient was scheduled for pene¬ trating keratoplasty in the right eye and this was performed by two of us (D. J. D. and R. L. L.) on May 26, 1976 with an organ-cultured cornea. A 7.5-mm recipient site was prepared, a partial anterior vitrec¬ tomy was performed, and an 8-mm donor button was sutured in place with running 10-0 nylon. The procedure went smoothly and without complications. The donor cornea was organ-cultured at 37 C, as described in earlier papers.'-- The donor cornea was harvested from a 31year-old man, a victim of an automobile accident, whose respiration was assisted mechanically and who had a flat EEG. The eyes were removed aseptically by one of us (P. A. L.) in the operating room at the same time the kidneys were being harvested by the transplant surgeons. Grossly, the eyes appeared to be in perfect condition. Vital signs of the donor had been well main¬ tained prior to harvest of the globes. The globe was flooded with a mixture of poly¬ myxin B sulfate, neomycin sulfate, and gramicidin (Neosporin) and stored at 4 C
Antifungal Sensitivities Torulopsis glabrata* MIC.
Amphotericin Natamycin Flucytosine Clotrimazole Miconazole Econazole
of
MCC,
fig/ml
/xg/ml
0.50 8.00 0.25 8.00 0.25 0.25
4.0 32.0 0.5 32.0 2.0 1.0
"MIC indicates minimal inhibitory concentra¬
tion; MCC, minimal cidal concentration.
added to the M-K media. Serum was not added. At this last media change, old and new media were streaked onto blood agar and Sabouraud's plates and cultured at 37 C and at room temperature to check steril¬ ity. Any growth on culture or turbidity of the M-K media causes the corneal button to be discarded and another cornea is selected that has been similarly quarantined. Post¬ operatively, the M-K media and the donor corneal rim are frozen for further investi¬
Fig
1 —Round white
mass
appearing
on
endothelial surface.
gation.
The graft did not clear well postopera¬ tively and had a pachometry reading of .78
June 1. Some vitreous haze was noted and prednisone therapy, 60 mg/day, was started on June 2 and tapered to 20 mg/ day, with some improvement by the time the patient was discharged on June 8. The patient also received topical 0.1% dexa¬ methasone every four hours while awake, 1.0% atropine sulfate twice daily, genta¬ micin sulfate drops twice daily, and 2.5% cellulose gum every four hours while she was awake. The patient continued to receive lowdose oral prednisone until July 13, at which time the patient had +1- + 2 flare, persis¬ tent graft edema, and a small white mass on the posterior cornea near the wound at the 12-o'clock position (Fig 1). The patient was rehospitalized for vigor¬ ous treatment of the suspected rejection episode. By the time she was discharged on June 20, the pachometry reading was .60 and the cornea was slightly clear, but the white mass at the 12-o'clock position was no smaller. On Aug 5, the mass at the 12-o'clock position was slightly larger. The patient continued to worsen and was rehospitalized on Aug 21. At this time a smaller white mass at the 11-o'clock position on the poste¬ rior cornea was first noted, as well as increasing vitreous haze. It was suspected that this was a stitch abscess and sutures were removed on Aug 22 without problems. The patient did not improve, and on Aug 25 an anterior chamber and vitreous tap were performed and the white mass at the 12o'clock position was partially excised on
Fig 2.—Luxuriant growth of Torulopsis glabrata from thawed storage media (left) and scierai rim (right) 24 hours after inoculation onto Sabouraud's plates. for a few hours prior to processing for organ culture. The cornea was removed from the globe with a 3-mm rim of sclera and placed epithelial side down in a dispos¬ able plastic Petri dish that contained 15 mm of minimal essential medium (MED). (The compositions of the organ culture media were as follows: MEM [Eagle's] with Earle's salts without L-glutamine, 500 ml; decomplemented calf or recipient serum, 50 ml; L-glutamine, 5 ml; penicillin, 100 units/ ml; streptomycin, 100 units/ml; amphoter¬ icin B, 0.25 µg/ml.) The dish was placed in a water-jacketed tissue culture incubator and maintained at 37 C in an atmosphere
air, 5% carbon dioxide, and 100% humidity. The MEM was changed three times weekly. All procedures were done with a sterile technique in a laminar flow hood. In our organ culture laboratory, any of 95%
contaminated cultures (turbid MEM) are discarded as soon as they are recognized. At surgery, if any turbidity is noted, the cornea is not used. At the time of this graft, we were placing the corneas in M-K media at 27 C for the last 48 hours preoperatively in order to obtain thin donor material. Penicillin, streptomycin, and amphotericin in the concentrations previously stated were
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
through
the keratoplasty wound. Smears from the white mass showed a budding yeast and vitreous cultures were 4+ posi¬ tive within 24 hours for glabrata, a Candida-like yeast of low pathogenicity whose hosts are usually diabetic and immu-
nosuppressed.""'
We retrieved and thawed the donor corneal rim and fluid. Both were cultured on Sabouraud's media and produced a luxu¬ riant growth of Torulopsis overnight
(Fig 2). Following current recommendations,"'5 treatment was started immediately with intravenously (IV) injected amphotericin B, oral flucytosine (2.5 gm four times a day), topical 1% flucytosine (one drop every four hours), and topical 0.5% amphotericin B. The latter was stopped shortly there¬ after because of local irritation. The IV amphotericin was started at 5 mg/day and by 5-mg daily increments, the patient reached 50 mg/day, at which point the 50mg dosage was given on an every-otherday schedule. Prednisone was tapered to 10 mg/day. A sample of the organism was sent to Daniel B.
Jones, MD, in Houston, who performed sensitivity tests (Table). On this regimen, the vitreous haze cleared,
cleared slowly, and the white the posterior cornea diminished until it was no longer visible on Sept 11 (Fig 3). The patient's urine and stool were cultured and no Torulopsis was found. Laboratory personnel who were involved with the organ culture and the two surgeons who performed the transplant were all found to be culture negative for glabrata on swabs from the nose, mouth, axilla, and groin. The floor and working counter in the organ culture room produced no Torulopsis on culture. was given until an Amphotericin accumulative IV dose of 475 mg was received, but this was discontinued on Sept 12, when lethargy, diarrhea, and nausea developed. Flucytosine was discontinued on Sept 14. At no time did the patient's creatinine level exceed 2.4 mg/100 ml, nor did the BUN level rise above 48 mg/100 ml. After the amphotericin and flucytosine were discontinued, the creatinine and BUN levels fell rapidly to pretreatment levels; they were 1.1 mg/100 ml and 13 mg/100 ml, respectively, on Sept 19 and remained near these values. In spite of normalization of renal function, the patient continued to have unrelenting nausea, lethargy, and diarrhea. Intravenous fluids were neces¬ sary to maintain hydration. Consults were obtained from the Infectious Disease, Endocrine, and Gastrointestinal Services, but no cause for the patient's systemic illness other than recent antifungal thera¬ py could be found. the
cornea
mass on
Fig
3.—White
On Sept 27, amphotericin no recurrence
mass on
endothelial surface
was no
12 days after cessation of and flucytosine, there was of the corneal deposits or
patient was transferred on Sept 27, after an episode of unresponsiveness with a blood glucose of 28 mg/100 ml that was treated with IV push D5„W· The patient sustained a cardiac arrest on the morning of Sept 28 and efforts at resuscitation were unsuccessful. Autopsy and eye removal requests were denied by the patient's family. vitreous haze. The
to the Endocrine Service
COMMENT
Torulopsis glabrata is an ovoid, slightly elongated yeast-like fungi that measures 2 to 3 µ by 3 to 4 µ. It fails to produce hyphae in tissues or culture and lacks a true capsule.'" Torulopsis glabrata was first isolated from human stool by Anderson10 in 1917 and named Cryptococcus glabra¬ ta. Lodder and de Vries introduced the
"Torulopsis glabrata" in 1937.7 In current taxonomy, glabrata is in the order Cryptococcales of asporogenous yeasts. This order contains a single family, Crytococcaceae, includ¬ ing mycelial and nonmycelial forms. A new subfamily, cryptococcideae, in¬ cludes the genera Candida, Torulop¬ sis, and Cryptococcus. Various reports in the literature state that glabrata causes such infections as fungemia, renal and urinary tract infections, and name
endocarditis.818"1"
Torulopsis glabrata
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
longer
visible
on
Sept 11, 1976.
has been isolated from the conjunc¬
tivas of normal adult eyes and has been implicated in lacrimal canal infections.2" Torulopsis gfabrata is apparently not a common inhabitant of the conjunctiva, however, as evi¬ denced by results of numerous studies of eye flora in which the organism has not been found.2123 To our knowledge, glabrata has not previously been implicated as an organism that is responsible for endophthalmitis. Most of the reports of infections involving glabrata were in patients who were generally debilitated, dia¬ betic, previously treated with antibi¬ otics, or immunosuppressed. Our pa¬ tient was an elderly diabetic woman who had been treated with rather large doses of oral steroids prior to the recognition of the glabrata endoph¬ thalmitis. We have no explanation why the Torulopsis grew well in less than 24 hours from the frozen rim and media postoperatively on a Sabouraud's plate, whereas the preoperative cul¬ tures were negative. Possible explana¬ tions are: (1) The organism was intro¬ duced from an operating room source, which contaminated both the donor cornea and rim; (2) The patient carried the organism; or (3) The orga¬ nism was present in the donor cornea and media preoperatively and was missed by the sterility checks we
employed
at the time of surgery.
In close
cooperation with the microbiologists we have modified our tech¬ nique of incubation and sterility checks in hopes of eliminating the possibility of any contamination of donor material going undetected. We have removed penicillin, streptomy¬ cin, and amphotericin from the last two media changes to allow any micro¬ organism to manifest itself prior to transplant and to eliminate the possi¬ bility of residual antimicrobials giv¬ ing false negative culture results. For its final media change, the cornea is placed in 60 mm of MEM in a large, sealed tube five to seven days prior to transplant. A larger volume is used to ensure adequate substrate for the survival of donor material. Ten milli¬ meter aliquots are taken from the last and next to the last media changes five to seven days prior to transplant and are sent to the main hospital Microbiology Department for aerobic, anaerobic, and fungal cultures at room temperature and at 37 C in enrich¬ ment broth. Although the endophthalmitis cleared on the regimen of IV, oral, and topical medications, it is interesting to speculate whether the lengthy hospi¬ tal stay and the eventual fatal outcome could have been altered by having used intraocular amphotericin with or without vitrectomy, as described by Peyman and Sanders21 and Forster et al.25 We also have no way of knowing whether the patient's own defenses may have eliminated the organism without treatment had steroids been withdrawn as soon as the infection with this low-virulence organism
was
recognized.
A four-month moratorium on or¬ gan-cultured corneas for transplant
observed after the discovery of the fungal endophthalmitis. No other infection occurred in our other trans¬ plant patients. Penetrating kerato¬ plasty with organ-cultured corneas was reinstated using our modified sterility checks in December 1976 and has continued to the present time at our institution without any evidence of infections. We do not know what role, if any, the organ-cultured cornea played in producing the endophthalmitis. Hope¬ fully, our modification of the organculture protocol will ensure against introduction of potential ocular path¬ ogens via donor material. was
Daniel B. Jones, MD, Houston, performed sensitivity studies on the organism.
the
Key Words.— Torulopsis glabrata; pene¬ trating keratoplasty; endophthalmitis; or¬ gan culture.
Names and Trademarks of Drugs
Nonproprietary
Amphotericin B—Fungizone. Flucytosine-A wcoòom. Gentamicin sulfate- Gara my ein. References 1. Doughman DJ, Harris JE, Schmidt MK: Penetrating keratoplasty using 37\s=deg\C. organ cultured corneas. Trans Am Acad Ophthalmol Otolaryngol 81:778-793, 1976. 2. Doughman DJ, Harris JE, Lindstrom RL, et al: Corneal preservation using 37\s=deg\organ culture incubation, in Lemp MA, King JH Jr (eds): Second World Congress on the Cornea, Boston, Little Brown & Co, to be published. 3. White JH: Fungal contamination of donor eyes. Br J Ophthalmol 53:30-33, 1969. 4. Le Francois M, Baum JL: Flavobacterium endophthalmitis following keratoplasty: Use of a tissue culture medium-stored cornea. Arch Ophthalmol 94:1907-1909, 1976. 5. Shaw EL, Aquavella JU: Pneumococcal endophthalmitis following grafting of corneal tissue from a (cadavor) kidney donor. Ann Ophthalmol 9:435-440, 1977. 6. Hasenclever HF, Mitchell WO: Pathogenesis
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of Torulopsis glabrata in physiologically altered mice. Sabouraudia 2:87-95, 1962. 7. Lodder J, de Vries NF: Some notes on Torulopsis glabrata (Anderson) nov comb. Mycopathologia 1:98-103, 1938. 8. Marks MI, Langston C, Eickhoff TC: Torulopsis glabrata: An opportunistic pathogen in man. N Engl J Med 283:1131-1135, 1970. 9. Pankey GA, Daloviso JR: Fugemia caused by Torulopsis glabrata. Medicine 52:395-403, 1973. 10. Anderson HW: Yeast-like fungi of the human intestinal tract. J Infect Dis 21:341-386, 1917. 11. Lieberman TW: Systemic antifungal chemotherapy in treatment of intraocular fungal infection, in Leopold IH (ed): Symposium Ocular Therapy. St Louis, CV Mosby Co Publishers, 1973, vol 6, pp 59-73. 12. Bennett JE: Chemotherapy of systemic mycosis, (first of two parts). N Engl J Med 290:30-31, 1974. 13. Bennett JE: Chemotherapy of systemic mycosis (second of two parts). (Part II), N Engl J Med 290:320-322, 1974. 14. Jones BR: Principles in the management of oculomycosis. Am J Ophthalmol 79:719-751, 1975. 15. Harder EJ, Hermans PE: Treatment of fungal infections with flu cytosine. Arch Intern Med 135:231-237, 1975. 16. Grimley PM, Wright LD, Jennings AE: Torulopsis glabrata infection in man. Am J Clin Pathol 43:216-223, 1965. 17. Kauffman CA, Tan JS: Torulopsis glabrata, renal infection. Am J Med 57:217-224, 1974. 18. Sharpe DN, Singh BM, Cornere BM, et al: Torulopsis glabrata endocarditis complicating aortic hemograft valve treated with 5-Fluorocytosine. N Z Med J 81:294-298, 1975. 19. Haley LD: Yeast of medical importance. Am J Clin Pathol 36:227-234, 1961. 20. Locatchar-Khorazo D, Seegal BC: Microbiology of the Eye. St Louis, CV Mosby Co Publishers, 1972, pp 208-240. 21. Tomar VPS, Sharma OP, Joshi K: Bacterial and fungal fluora of normal conjunctiva. Ann Ophthalmol 3:669-671, 1971. 22. Williamson J, Gordon AM, et al: Fungal flora of the conjunctival sac in health and disease. Br J Ophthalmol 52:127-137, 1968. 23. Polack FM, Locatcher-Khorazo D, Gutierrez E: Bacteriologic study of "donor" eyes: Evaluation of antibacterial treatments prior to corneal grafting. Arch Ophthalmol 78:219, 1967. 24. Peyman GA, Sanders DR: Advances in Uveal Surgery, Vitreous Surgery, and the Treatment of Endophthalmitis. New York, Appleton\x=req-\ Century-Crofts, 1975, pp 179-228. 25. Forster RK, Zachary IG, et al: Further observations on the diagnosis, cause, and treatment of endophthalmitis. Am J Ophthalmol 81:52\x=req-\ 56, 1976.
