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CASE REPORTS
ENTEROCOCCUS FAECALIS IN CONJUNCTIVAL SWAB FROM A DIABETIC PATIENT
ROOPA VISWANATHAN
Enterococcal conjunctivitis has not been reported till now to the best of our knowledge. Below is a case report of conjunctival swab yielding ‘Enterococcus faecalis’ in culture.
INTRODUCTIONAmongst gram positive cocci, conjunctivitis is caused mainly by Staph aureus, Staph epidemidis, Str. pneumoniae, Str. viridans and Str. pyogenes”. Here we report an unusual case of Enterococcus faecalis isolated from a conjunctival swab.
CASE REPORT
A 79 year old male with insulin dependent diabetes mellitus presented with redness of left eye with normal vision and yellowish discharge. He had no other complaints. He had undergone cataract operation 7 months back in the same eye.
On examination, there was conjunctival injection in the left eye with serosanguinous discharge. The cornea was clear. Pupils were normal. Intraocular pressure was normal.
Fundoscopic examination and sonography suggested ?Retinal vein blockade.
The conjunctival swab was sent for culture and sensitivity. The Gram’s stain of the conjunctival smear showed Gram positive angulated diplococci. The culture grew pure colonies of “Enterococcus faecalis” identified by standard microbiological techniques.
The strain of “Enterococcus faecalis” was found sensitive to Ampicillin, Amoxycillin, Penicillin, Ciprofloxacin, Norfloxacin, Ofloxacin, Amoxycillin + Clavulinic acid, Sulbactum + Ampicillin, Tobramycin, Gentamycin, Netilmycin, Vancomycin and Linezolid.
As a result, the patient was subjected to Ofloxacin eyedrops every 2 hours. After two days, repeat conjunctival swab was collected and was sent for culture. The Gram’s smear again showed very few Gram positive angulated diplococci but the culture yielded no growth.
The patient recovered in 5 days whereby his redness and discharge in the left eye subsided and disappeared. Repeat culture yielded no growth.
DISCUSSION
Enterococcal infections are on the rise in present scenario. The resistance of Enterococcus to multiple antimicrobials is responsible for the organism to survive and proliferate in prolonged antimicrobial chemotherapy1 and hence it is associated with patients on antibiotics. The organism generally is known to cause urinary tract infection in catheterised patients. It is also known to cause pyogenic infection like intraabdominal, pelvic infection and endocarditis.
In diabetes mellitus, neutrophil phagocytosis is affected which makes the patients susceptible to enterococcal infections besides infection due to Enterobacteriaceae, Staphylococci, Pseudomonas, Candida, Aspergillus, Mucor, etc.2 As far as eye infection with enterococcus is concerned enterococcal endophthalmitis has been reported in diabetic patients who had enterococcal bacteraemia from a diabetic foot infection several months after undergoing vitrectomy for diabetic retinopathy.3 This implies that enterococcus is an opportunistic pathogen. The present case is a unilateral conjuncivitis, due to exogenous inoculation into the eye, of enterococcus, whose source is not known. The infection is exogenous as there is no symptoms or signs suggestive of any underlying systemic infection.Ofloxacin is known to show good in vitro activity against enterococcus4 but its overall effectiveness in vivo in general is questionable.5 But here, the invitro susceptibility of “Enterococcus faecalis” to Ofloxacin has confirmed with the clinical response of the patient. The organism though seen in smear and not grown in culture only confirms its nonviability owing to the antimicrobial therapy.
In conclusion, here is an unusual case of unilateral exogenous enterococcal conjunctivitis in a diabetic patient which could have been missed had the culture not been performed. The antibiotic susceptibility testing showed sensitivity to Ofloxacin, which relieved the patient clinically of the infection.
REFERENCES
1. Moellering RC Jr. Streptococcal infections Chapter 189. In:Mandell, Douglas and Bennett’s Principles and practice of infectious diseases, 5th edition Vol. 2, Philadelphia: Churchill Livingstone. 2000: 2146-7.
2. Rogers TR. Infection associated with immunodeficiency. Chater3.10. In: Topley Wilson’s Principles of Bacteriology, virology and immunity, 8th edition Vol. 3. London: Edward Arnold. 1990: 173-4.
3. Moellering RC Jr. Streptococcal infection chapter 189. In:Mandell, Douglas and Bennett’s principles and practice of infectious diseases, 5th edition Vol. 2 Philadelphia: Churchill Livingstone. 2000: 2149.
4. Martinez-Martinez L, Joyanas P, Pascual A, et al. Activity of eight fluoroquinolones against enterococci. Clin Microbiol
Infect 1997; 3 : 497.
5. Schaberg DR, Dillion WI, Terpenning MS, et al. Increasing resistance of enterococci to ciprofloxacin. Antimicrobs
Agents Chemother 1992; 36 : 2523-35.
