Epidemiologic Notes and Reports Mycobacterium chelonei Infections Following Eye Surgery -- Texas

In December 1982, the Texas Department of Health (TDH) received reports that two patients from different parts of the state had Mycobacterium chelonei eye infections following dacryo-cysto-rhinostomy (DCR) and implantation of silicon tubing from a canaliculus intubation set. After the report of these cases in Texas Preventable Disease News in May 1983, two additional cases of M. chelonei eye infections were reported.

Case 1: In April 1981, a 52-year-old woman from southern Texas with chronic tearing of both eyes of several years' duration underwent DCR on the left eye and opening of the punctum on the right. Adequate tear drainage was immediately achieved in the left eye; tearing on the right eventually resumed. On September 16, 1982, she underwent a DCR on the right side and implantation of a Guibor* silicon tube. Anesthesia included 10% cocaine and 2% xylocaine. An ointment composed of dexamethazone, neomycin, and polymyxin B was applied to the incision and the eye after surgery.

Before surgery, the patient frequently had "puffy eyelids," reportedly related to allergic sinusitis. Therefore, when she developed puffy eyelids after surgery, they were attributed to sinusitis, and as a result, a specimen for culture was not obtained until November 12, 1982. The culture yielded M. chelonei subspecies abscessus susceptible to kanamycin, amikacin, cefoxitin, and minocycline. The infection resolved after treatment with amikacin, and the tube was removed on May 9, 1983.

Case 2: An 89-year-old woman from central Texas had recurrent dacryocystitis of 3 years' duration in the left eye. Repeated cultures of the eye yielded Staphylococcus aureus. The patient had undergone DCRs in April 1979 and August 1981 to relieve chronic staphylococcal conjunctivitis and dacryocystitis. On May 15, 1982, she underwent a revision of the previous DCR under general anesthesia; the brand name of the implanted tube was not recorded. The patient was discharged with prescriptions for dicloxacillin, tobramycin, and bacitracin ointment. In early November, purulent drainage from the left eye developed. A specimen for culture taken November 10 yielded M. chelonei subspecies abscessus which was susceptible to kanamycin, amikacin, and cefoxitin. The infection resolved following treatment with topical tobramycin and oral erythromycin. The implanted material has not been removed.

Case 3: A 78-year-old woman from northeastern Texas had a history of chronic conjunctivitis and bilateral occluded lacrimal ducts. Cultures of the lid margins and conjunctivae yielded Staphylococcus epidermidis. On March 1, 1983, she underwent a bilateral DCR under general anesthesia. Silastic tubing had been purchased in large quantities directly from the manufacturer and sterilized at the hospital where the surgery was performed. No irrigants or flushing solutions were used, although methylene blue was injected into the canaliculi for dilatation. After surgery, Afrin* nasal spray, and Neosporin* and Maxitol* ointments were used. Recovery was uneventful until April 17, when a profuse discharge was noted. Cultures yielded M. chelonei subspecies abscessus susceptible to kanamycin, amikacin, erythromycin, and cefoxitin. After treatment with topical amikacin and removal of the tubes, the discharge cleared.

Case 4: A 60-year-old man from central Texas had a history of a cataract and epithelial edema in the left eye. On April 13, 1983, extra-capsular cataract extraction, lens implant, corneal transplant, and peripheral iridectomy were performed on the left eye under general anesthesia. The McGhan 3M Implens 30* was received sterile from the supplier. The donor cornea had been cultured previously, and no growth had occurred within 48 hours. Only sterile filtered solutions were used during surgery. After surgery, AK-pred*, AK sporin*, Tobrex*, and Timoptic* were administered to the eye. On June 8, mucus was noted to be covering the suture area, and on June 9, an ulcerated area was noted. A specimen taken for culture at this time was negative after 48 hours. By July 5, infiltrative keratitis developed at the graft junction. A specimen taken for culture at this time grew M. chelonei subspecies abscessus. The infection resolved following topical amikacin therapy.

Detailed examination of the medical records of the four patients failed to reveal any common medications or devices. No similar infections had been noted among other patients undergoing eye surgery in the four hospitals. Review of records from the TDH Mycobacteriology Laboratory for 1981 and 1982 did not reveal any additional eye cultures positive for M. chelonei, nor did review of records from the mycobacteriology labortories at the National Jewish Hospital in Denver or the University of Texas at Tyler. During 1981 and 1982, CDC's mycobacteriology laboratory received two isolates of M. chelonei from two individuals who had undergone cataract extraction in Georgia. Reported by W Dansby, AB Morgan, MD, Seton Hospital, Austin, WN Gilhum, MD, V Rial, Knapp Memorial Methodist Hospital, MF Butler, Medical Plaza Hospital, JL Bussey, MD, Ophthalmology Associates, Fort Worth, JD Broderick, MD, G Charns, Medical City Hospital, Dallas; JE Steadham, Bureau of Laboratories, TL Gustafson, MD, Acting State Epidemiologist, Texas Dept of Health; Div of Field Svcs, Epidemiology Program Office, Respiratory and Special Pathogens Epidemiology Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: M. chelonei are rapidly growing nontuberculous mycobacteria that are widely present in the environment. Recently, their role in human illness has been recognized with increasing frequency in many different clinical settings (1). Ocular infections with M. chelonei are rare, but cases of keratitis and orbital granuloma following trauma or surgery have been reported (2,3). However, the incidence of such infections is unknown.

Although all the cases reported here occurred in one state over a limited period of time, followed similar operative procedures, and involved a single M. chelonei subspecies, the epidemiologic investigation failed to identify a common vehicle or source of infection. While it is possible that a common factor was present and not uncovered by the investigation, this suggests that these cases were sporadic in nature and that such infections may be more common than previously recognized.

Physicians should be alert to the possible existence of ocular mycobacterial infections following surgery or trauma and should be aware that routine culture methods may not yield a positive result before they are discarded. Therefore, if a nontuberculous mycobacterial infection is suspected, specimens should be examined with stains for acid-fast organisms, and cultures for nontuberculous mycobacteria should be obtained. Treatment, which should be guided by antimicrobial susceptibility testing of the mycobacterial isolate, may require a combination of antimicrobial agents.

References

1. Wallace RJ, Swenson JM, Silcox VA, Good RC, Tschen JA, Stone MS. Spectrum of disease due to rapidly growing mycobacteria. Rev Infect Dis 1983;5:657-79.

2. Meisler DM, Friedlaender MH, Okumoto M. Mycobacterium chelonei keratitis. Am J Ophthalmol 1982;94:398-401.

3. Smith RE, Salz JJ, Moors R, Silverstein D, Lewis W. Mycobacterium chelonei and orbital granuloma after tear duct probing. Am J Ophthalmol 1980;89:139-4l.

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