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All the data supporting the conclusions of this article are contained within the manuscript. Postoperative endophthalmitis after cataract surgery is a severe eye infection that can lead to irreversible blindness in the affected eye. The characteristics, treatment and prognosis of this disease vary because of its association with different pathogens.
Here, we report what is possibly the first case of endophthalmitis after cataract surgery to be associated with the rare pathogen Earliella scabrosa. A year-old man from Hainan Island China with a history of phacoemulsification and type II diabetes mellitus underwent intraocular lens IOL implantation. He later presented with progressive endophthalmitis in his right eye.
IOL explantation with capsular bag removal and a 23G pars plana vitrectomy combined with a silicone oil tamponade was performed. An in vitro culture determined that the causative pathogen was Earliella scabrosa , and this result was confirmed by an internal transcribed spacer ITS sequence analysis. Earliella scabrosa has never been reported as an infectious agent in human eyes, and its clinical significance remains unknown.
Here, we report a rare case of Earliella scabrosa -associated endophthalmitis after cataract surgery. The fungal infection presented as an acute attack and was successfully treated with vitrectomy.
Postoperative endophthalmitis is one of the most severe complications of cataract surgery and can result in extremely poor vision. However, its causative pathogens vary among different regions. Different fungi have been identified as a prime causative agents in developing countries with tropical and subtropical climates.
For example, Anand et al. Another large case series from India involved eyes and revealed that over half of the cases involved a fungal infection [ 2 ]. The spectrum of fungi described in previous studies includes Aspergillus spp. To the best of our knowledge, ours is the first reported case of endophthalmitis after cataract surgery to be associated with the rare pathogen Earliella scabrosa. A year-old male patient with a history of type II diabetes mellitus was referred to the Hainan Eye Hospital Haikou, China for a red and painful right eye with poor vision.
One month before admission, the patient underwent phacoemulsification and IOL implantation in a local hospital. However, the patient missed this follow-up visit, and he applied the levofloxacin eye drops for 1 month. At 1 month after his presentation at the private clinic, his signs and symptoms had not improved.
Acute post-cataract endophthalmitis was suspected. Photographs of the infected ocular area. In addition, a vitreous biopsy was obtained for culture. Fortified tobramycin and levofloxacin eye drops were started after the vitrectomy and continued for 6 days. The vitreous fluid was cultured in Sabouraud dextrose agar SDA.
Seven days later, white colonies formed and were identified as Earliella scabrosa via internal transcribed spacer ITS sequence analysis. The hyphae stained positive for acridine orange, exhibiting an extremely thick cell wall, sparse septae, and internal nuclei Fig.
The morphological characteristics of Earliella scabrosa. The isolates were identified by sequencing the ITS region as previously described [ 3 ]. Most acute post-cataract endophthalmitis cases reported worldwide are caused by bacterial infections [ 4 , 5 ].
The patient was then suspected to suffer from acute endophthalmitis induced by bacterial infection. Therefore, empirical treatment consisting of a vitrectomy followed by intraocular irrigation with vancomycin was administered. However, Earliella scabrosa , a type of fungus, was isolated from the vitreous fluid and identified by sequencing the ITS region.
In retrospect, this case is not the only acute endophthalmitis case associated with fungi. Although fungal-associated, acute, post-cataract endophthalmitis is rare, dozens of cases have been reported in tropical regions [ 6 ]. Aspergillus spp.
Earliella scabrosa is a genus of fungi named by Gilbertson and Ryvarden in that belongs to the family Polyporaceae [ 7 ]. Earliella scabrosa is considered a plant pathogen, exhibiting a strong association with freshwater forested wetlands in tropical areas, such as Micronesia [ 8 ]. Notably, a recent case report published by Desmond Shi-Wei Lim et al.
However, data regarding human disease remains limited. Here, we report a case in which a human eye infection was associated with Earliella scabros a. Several points should be noted in this report. First, Earliella scabrosa appears to be a novel opportunistic pathogen that can cause endophthalmitis after a cataract extraction.
This disease can impair the immune response of a patient and increase the risk of infection after an operation [ 10 ]. Second, ITS sequence analysis is a reliable molecular method for fungal identification, especially for a rare pathogen [ 11 ]. As mentioned previously, data on Earliella scabrosa are limited; therefore, the pathogen isolated from the patient in this case was considered to be an unidentified contaminant, given the lack of morphological characteristics and an absence of sporulation.
This fungus was finally identified by genomic level evidence. Third, endophthalmitis induced by Earliella scabrosa may have a favorable prognosis. IOL explantation with capsular bag removal and a 23G pars plana vitrectomy combined with silicone oil tamponade seemed to be an effective treatment. However, in this case, the course was mild. One potential reason for this discrepancy is that the characteristics of the site of initial presentation were different.
The vascular network within the skin may have facilitated the formation of vascular emboli by fungal hyphae, resulting in the dissemination of the infection and multi-organ involvement. On the contrary, the vitreous of the eye can, to some extent, restrict the dissemination of a pathogen because it contains no blood vessels and is a poor nutritional source for invading agents [ 12 ].
Another potential reason was that there were differences in the general physical condition of the two patients. The adult patient had type II diabetes but was in generally stable physical condition. In addition to the fungal infection, the child had severe idiopathic aplastic anemia and was suffering from graft failure, intracranial hemorrhage and multiple bacterial infections.
Environmental risk factors were not assessed in our study because the surgery was performed in a local hospital before the patient was referred to Hainan Eye Hospital. In conclusion, in this case, we reveal that Earliella scabrosa , a rare known fungal agent, was the underlying etiology in a human eye infection. These data reinforce the need to enhance awareness of fungal infections in acute endophthalmitis. Early diagnosis and prompt surgical treatment can improve the prognosis in affected patients.
All authors made substantial contributions to conception and design. XZ and HL were involved in the analysis. HH wrote the first draft of the manuscript. All authors were involved in revising the manuscript critically for important intellectual content. And XZ has given final approval of the version to be published.
All authors read and approved final manuscript. Informed consent for participation were obtained from the patient before examination and surgery. Informed consent for publication were obtained from the patient before examination and surgery.
All authors have seen the manuscript and approved to publish it to the journal. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. National Center for Biotechnology Information , U. BMC Ophthalmol. Published online Feb Author information Article notes Copyright and License information Disclaimer.
Xingwu Zhong, Phone: , Email: moc. Corresponding author. Received Jul 25; Accepted Jan Associated Data Data Availability Statement All the data supporting the conclusions of this article are contained within the manuscript. Abstract Background Postoperative endophthalmitis after cataract surgery is a severe eye infection that can lead to irreversible blindness in the affected eye. Case presentation A year-old man from Hainan Island China with a history of phacoemulsification and type II diabetes mellitus underwent intraocular lens IOL implantation.
Conclusion Earliella scabrosa has never been reported as an infectious agent in human eyes, and its clinical significance remains unknown. Keywords: Postoperative Endophthalmitis, Earliella scabrosa , Ocular fungal infection. Background Postoperative endophthalmitis is one of the most severe complications of cataract surgery and can result in extremely poor vision.
Case presentation A year-old male patient with a history of type II diabetes mellitus was referred to the Hainan Eye Hospital Haikou, China for a red and painful right eye with poor vision. Open in a separate window. Discussion and conclusion Most acute post-cataract endophthalmitis cases reported worldwide are caused by bacterial infections [ 4 , 5 ]. Availability of data and materials All the data supporting the conclusions of this article are contained within the manuscript.
Consent for publication Informed consent for publication were obtained from the patient before examination and surgery. Competing interests The authors declare that they have no competing interests. References 1. Spectrum of etiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol. Spectrum and clinical profile of post cataract surgery endophthalmitis in north India.
Coster D. Curr Eye Res ; — Evaluation of bacterial contamination rate of the anterior chamber during phacoemulsification surgery using an automated microbial detection system. Int J Ophthalmol.
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Earliella scabrosa (Pers.) Gilb. & Ryvarden
Earliella is a fungal genus in the family Polyporaceae. It is a monotypic genus, containing the single species Earliella scabrosa. The genus was circumscribed by William Alphonso Murrill in with Earliella cubensis as the type species. The type collection was made in Cuba by Murrill and Franklin Sumner Earle , for whom the genus is named. Murrill also noted the presence of the fungus in Nicaragua, Mexico, and Jamaica. The chemical constituents and antioxidant activity of the essential oil extracted from fruit bodies of Earliella scabrosa has been characterized.