Journals | Policy | Permission

This journal has moved to cii.elmerpub.com Please go to the new site to make submissions

Clinical Infection & Immunity

Case Report

Volume 1, Number 2, December 2016, pages 48-49

Actinobacillus ureae Isolated After Traumatic Eye Injury

Genetic and phenotypic studies have shown members of genus pasteurella are closely related to the animal species in the genus actinobacillus. Actinobacillus ureae is an uncommon commensal of the human respiratory tract and a rare isolate from several types of human infections,including bacteremia, endocarditis, meningitis, bone marrow infection, atrophic rhinitis,bronchitis, pneumonia, conjunctivitis, otitis media and peritonitis. Mostly, an underlying condition has been accompanied. Meningitis cases usually after skull trauma or surgery were reported [1].

We report here a rare case of A. ureae presenting with intraocular infection after trauma. A 50-year-old male patient was admitted to our emergency service with history of wood injury to his right eye with vegetation and severe pain lasted for 5 days. There were burring, swelling and redness. His eye examination revealed corneal abcess formation and intense hypopion in anterior chamber and his visual acuity was at grade of light reflex on right eye. The patient’s ocular and medical history was negative, and he denied either taking medication or having allergies. Slit lamp evaluation revealed diffuse conjunctival injection and underlying stromal infiltration in the midperiphery of the right eye. The patient had great amounts of mucopurulent discharge. Corneal erasure was taken with swab and sent to microbiology laboratory to perform culture before treatment was initiated. Afterwards fortified vancomycin and fortified ceftazidime per hour and sodium hyaluronate 6 × 1 and cyclopentholate 3 × 1 had started. On his second day of treatment, spontaneous corneal perforation developed and patient was hospitalized and IV antibiotic regimen had started. Tight bandage had applied to his eye. A. ureae was grown in his wound specimen culture. The patient did not get better, so drug was changed to piperacilline tazobactam due to antibiogram findings. In his follow-up, infection findings had decreased but phthisis bulbi and total visual impairment developed. His eye examination was seen in Figure 1.

Click for large image

Figure 1. In the follow-up, infection findings had decreased but phthisis bulbi and total visual impairment developed.

A. ureae is a gram negative, pleomorphic, facultatively anaerobic bacillus. Colonies after 24-h incubation on blood agar in a CO₂-enriched atmosphere usually appear as smooth, non-hemolytic, and grow weak on MacConkey agar and catalase-oxidase positive. They strongly catalyze urea. Some obvious phenotypic differences are observed between species A. ureae and other Actinobacillus species. Actinobacillus reproduces slowly in 48 - 72 h. Colonies are small, transparent, irregular, and translucent. Bacilli tend to extend in subsequent cultures. Organisms are catalase(+), oxidase(-). A. ureae is urease(+) and does not need X factor to grow and other species are urease negative. They are all carbohydrate fermenters [2]. In the pediatric group, it may be surprising to see as causative agent of conjunctivitis. The culture is quite simple and clinicians mostly use empirical and topical antimicrobial therapy to treat acute conjunctivitis [3-5]. Because the disease is easily cured and culture may take days; the causative agent is mostly unknown. In our case, antibiotic susceptibility of A. ureae is made by disk diffusion method, clindamycin, gentamycin, tetracycline, amikacin, ciprofloxacin, piperacillin-tazobactam and colistin sensitive. The organism was resistant to aztreonam, oxacillin, teicoplanin, erythromycin, amoxicillin clavulanate, norfloxacin and ceftazidime. A. actinomycetemcomitans is also another gram negative member in this genus associated with endocarditis, bacteremia, and dental injuries. Spores remain dormant, and often associated with actinomycosis of Actinomyces israelii isolated abscesses. The most common infection is acute bacterial endocarditis. There is a subacute serious process because of virulance factors. Virulence factors identified include leukotoxin, TMN-chemotaxis inhibitory factor, fibrinogen inhibitor factor, bone marrow destruction and collagenase enzyme inducing factor and lipopolysaccharide endotoxin. Other actinobacillus types also may be isolated from a systemic or localized infection. Rarely, chronic granulomatous lesions and lymph adenitis caused by A. lignieresii in the upper part of the digestive system also have been reported [1]. Trauma, either chemical, thermal, surgical, or penetrating, is also a common cause of corneal perforation. Chemical injuries, alkali burns in particular, may cause devastating corneal damage, initially by direct tissue destruction and later by induction of stromal melting and necrosis because of the elaboration of collagenases. Thermal injury normally causes superficial corneal damage but may, in rare instances, cause perforation because of extreme heat or associated mechanical injury [6]. Corneal ulceration and perforation have also been reported after cataract extraction, both with and without intraocular lens implantation [7]. Penetrating eye injuries are common and studied by many researchers because of their dramatic visual results. The prognostic factors are summarized in studies as visual acuity, the types and mechanisms of trauma, the placement and size of the wound, the presence of pupillary defect, vitreous hemorrhage, lenticular injury, retinal detachment and endophthalmitis development [8].

1. Winn, et al. Koneman's Color Atlas and textbook of Diagnostic Microbiology. Sixth edition. Miscellaneous fastidious gram-negative bacilli. chapter 9. 452-458.
2. Bilgehan H. Basic Microbiology. Gunes press. 2000.
3. Ergin C, Kaleli I, Kilic I. Acute conjunctivitis caused by Actinobacillus ureae. Pediatr Int. 2007;49(3):412-413.
   doi pubmed
4. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clin Ther. 1995;17(5):800-810; discussion 779.
   doi
5. Orden Martinez B, Martinez Ruiz R, Millan Perez R. [Bacterial conjunctivitis: most prevalent pathogens and their antibiotic sensitivity]. An Pediatr (Barc). 2004;61(1):32-36.
   doi
6. Honig Marc A, et al. Management of Corneal Perforations. https://www.us.elsevierhealth.com/media/us/samplechapters/9780323023153/Chapter%2037.pdf.
7. Md Noh UK, Then KY. Spontaneous bilateral corneal perforation in stevens- johnsons syndrome-a challenge in management. Malays J Med Sci. 2013;20(1):84-87.
   pubmed
8. Coskun M, Atas M, Akal A, Ilhan O, Keskin U, Tuzcu EA. [The factors affecting the development of phthisis bulbi after penetrating eye injuries]. Ulus Travma Acil Cerrahi Derg. 2012;18(4):317-320.
   doi pubmed

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Clin Infect Immun is published by Elmer Press Inc.