Post-Keratoplasty Infectious Keratitis Caused By Elizabethkingia Meningoseptica

Microbial keratitis is a major complication of keratoplasty that is associated with serious ocular sequalae if not adequately treated. The purpose of this case report is to present a case of infectious keratitis following keratoplasty caused by the rare microorganism Elizabethkingia meningoseptica.

A 73-year-old patient presented to the outpatient clinic complaining of a sudden decrease of vision in his left eye. The right eye was enucleated during childhood due to ocular trauma and an ocular prosthesis was placed in the orbital socket. He underwent penetrating keratoplasty 30 years ago for corneal scar and repeated optical penetrating keratoplasty for failed graft in 2016. He was diagnosed with microbial keratitis following optical penetrating keratoplasty in the left eye.

On presentation, the patient complained of a sudden decrease of vision in his left eye for the duration of 2 months. On examination, the visual acuity of the left eye was 20/200. The intraocular pressure of the left eye was 12 mmHg. Anterior segment examination of the left eye showed diffuse graft edema and inferior graft infiltrate involving the anterior stroma measuring 1.5×2 mm with an overlying corneal epithelial defect measuring 2×3 mm and adjacent neovascularization. The anterior chamber was deep, with a 0.8 mm white hypopyon. The patient was admitted, and scraping of the corneal infiltrate was performed for the left eye and sent for microbiological investigation (Gram staining, Giemsa Staining, and microbiological culture). 

Corneal scraping of the infiltrate showed growth of the gram-negative bacteria Elizabethkingia meningoseptica. Conjunctival swab of the orbital socket of the fellow eye was positive for the same microorganism. Antimicrobial susceptibility testing indicated that the microbial isolate was resistant to ceftazidime and gentamicin. Therefore, topical moxifloxacin 0.50% was started every 4 hours in both eyes and with daily followup. Two weeks later, the patient’s visual acuity was 20/100. Examination of the eye revealed a healed corneal epithelial defect, resolved hypopyon, and corneal scarring. After 2 months, the patient’s vision improved to 20/60. The graft was clear, with a faint superficial scar at the site of the previous infiltrate.

Microbial keratitis is a serious complication following penetrating keratoplasty. An infected orbital socket could be a risk factor of microbial keratitis of the fellow eye. A high index of suspicion, along with timely diagnosis and management, may improve the outcome and clinical response and reduce the morbidity associated with these infections. This case highlights the occurrence of keratitis in a corneal graft secondary to an infection of the fellow orbital socket with the unusual organism E. meningoseptica, which was found to be sensitive to fluoroquinolone. Further studies on orbital socket infection as a source of microbial keratitis in the contralateral eye are suggested.