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      Delayed onset Mycobacterium intracellulare keratitis after laser in situ keratomileusis : A case report and literature review

      case-report
      , MD a , , MD b , , MD, PhD c , , MD, PhD a , , MD, PhD a , d ,
      Medicine
      Wolters Kluwer Health
      keratitis, mycobacterium, Mycobacterium intracellulare, post-LASIK keratitis

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          Abstract

          Rationale:

          Infectious keratitis is a relatively uncommon but potentially sight-threatening complication of laser in situ keratomileusis (LASIK). Mycobacterial keratitis is usually regarded as late onset keratitis among post-LASIK keratitis. There has been no documented case of Mycobacterium intracellulare post-LASIK keratitis of a long-latent period.

          Patient concerns:

          A 36-year-old man was referred to our out-patient clinic, for persistent corneal epithelial defect with intrastromal infiltration. He had undergone uneventful bilateral LASIK procedure 4 years before. He complained decreased vision, accompanied by ocular pain, photophobia, and redness in his left eye for 7 months.

          Diagnosis:

          Lamellar keratectomy was taken using femtosecond laser. Bacterial culture with sequenced bacterial 16s ribosomal DNA confirmed the organism to be M intracellulare.

          Interventions:

          After 3 months of administration of topical clarithromycin, amikacin, and moxifloxacin, the corneal epithelial defect was resolved and the infiltration was much improved. However, newly developed diffuse haziness with surrounding granular infiltration in the central cornea was noted. Drug toxicity was suspected and topical moxifloxacin was discontinued, resulting in resolution of the diffuse haze with infiltration.

          Outcome:

          The patient was followed up regularly without medication thereafter and recurrence was not found for 7 years.

          Lessons:

          This case presents the first case of M intracellulare keratitis after LASIK. LASIK surgeons should aware that post-LASIK keratitis can develop long after the operation and careful suspicion of infectious disease with meticulous diagnostic test is needed.

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          Most cited references20

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          Sliding motility in mycobacteria.

          Mycobacteria are nonflagellated gram-positive microorganisms. Previously thought to be nonmotile, we show here that Mycobacterium smegmatis can spread on the surface of growth medium by a sliding mechanism. M. smegmatis spreads as a monolayer of cells which are arranged in pseudofilaments by close cell-to-cell contacts, predominantly along their longitudinal axis. The monolayer moves away from the inoculation point as a unit with only minor rearrangements. No extracellular structures such as pili or fimbriae appear to be involved in this process. The ability to translocate over the surface correlates with the presence of glycopeptidolipids, a mycobacterium-specific class of amphiphilic molecules located in the outermost layer of the cell envelope. We present evidence that surface motility is not restricted to M. smegmatis but is also a property of the slow-growing opportunistic pathogen M. avium. This form of motility could play an important role in surface colonization by mycobacteria in the environment as well as in the host.
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            Infections following laser in situ keratomileusis: an integration of the published literature.

            Infections occurring after laser in situ keratomileusis (LASIK) surgery are uncommon, but the number of reports have steadily increased in recent years. This systematic, comprehensive review and analysis of the published literature has been performed in order to develop an integrative perspective on these infections. We have stratified the data by potential associations, microbiology, treatment, and the degree of visual loss, using Fisher's exact tests and Student's t-tests for analysis. In this review, we found that Gram-positive bacteria and mycobacterium were the most common causative organisms. Type of postoperative antibiotic and steroid use was not associated with particular infecting organisms or severity of visual loss. Gram-positive infections were more likely to present less than 7 days after LASIK, and they were associated with pain, discharge, epithelial defects, and anterior chamber reactions. Fungal infections were associated with redness and tearing on presentation. Mycobacterial infections were more likely to present 10 or more days after LASIK surgery. Moderate or severe visual reductions in visual acuity occurred in 49.4% of eyes. Severe reductions in visual acuity were significantly more associated with fungal infections. Flap lift and repositioning preformed within 3 days of symptom onset may be associated with better visual outcome.
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              Nontuberculous mycobacterial infections.

              Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which have only recently been recognized as pathogenic. The diagnosis of mycobacterial disease is based on a combination of clinical features, microbiologic data, radiographic findings, and histopathologic studies. To provide an overview of the clinical and pathologic aspects of nontuberculous mycobacteria infection, including diagnostic laboratory methods, classification, epidemiology, clinical presentation, and treatment. Review of the pertinent literature and published methodologies. Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which are potentially pathogenic, and are classified according to the Runyon system based on growth rates and pigment production. Their slow growth hinders cultures, which require special medium and prolonged incubation. Although such methods are still used, newer nucleic acid-based technologies (polymerase chain reaction and hybridization assays) can rapidly detect and speciate some mycobacteria--most notably, distinguishing Mycobacterium tuberculosis from other species. Infections caused by these organisms can present as a variety of clinical syndromes, not only in immunocompromised patients but also in immunocompetent hosts. Most common among these are chronic pulmonary infections, superficial lymphadenitis, soft tissue and osteoarticular infections, and disseminated disease. Treatment of nontuberculous mycobacterial infections is difficult, requiring extended courses of multidrug therapy with or without adjunctive surgical intervention.
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Wolters Kluwer Health
                0025-7974
                1536-5964
                December 2017
                22 December 2017
                : 96
                : 51
                : e9356
                Affiliations
                [a ]Department of Ophthalmology, Corneal Dystrophy Research Institute, Institute of Vision Research, Yonsei University College of Medicine
                [b ]Nune Eye Hospital
                [c ]Research Institute of Bacterial Resistance, Department of Laboratory Medicine, Yonsei University College of Medicine
                [d ]Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea.
                Author notes
                []Correspondence: Eung Kweon Kim, Department of Ophthalmology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea (e-mail: eungkkim@ 123456yuhs.ac ).
                Article
                MD-D-17-06932 09356
                10.1097/MD.0000000000009356
                5758224
                de261500-1251-43aa-89e4-ebf5e78c55b5
                Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

                History
                : 16 November 2017
                : 28 November 2017
                Categories
                5800
                Research Article
                Clinical Case Report
                Custom metadata
                TRUE

                keratitis,mycobacterium,mycobacterium intracellulare,post-lasik keratitis

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