Case Reports

Acidovirax keratitis – a rare case of bilateral insidious keratitis secondary to fruit contamination successfully treated with phototherepeutic keratectomy and mitomycin C

Case Report Details

First Author: N.Din UK

Co Author(s):    S. Hamid   M. Phylactou   M. Wilkins              

Abstract Details

Purpose:

Infectious keratitis is an important cause of ocular morbidity worldwide with early diagnosis and effective treatment resulting in a favourable outcome. To describe a rare case of bilateral infectious epithelial keratopathy secondary to contact with bacterial contaminated watermelon fruit, and its successful treatment. To our knowledge, this is the first report of such a case in the literature.

Setting:

Moorfields Eye Hospital, London, UK

Report of Case:

We report a case of a 59-year-old man with symptoms of ocular pain, redness and blurred vision after contact with contaminated watermelon fruit. He had no past ocular history. He denied any previous trauma, contact lens wear, recent fresh water activities and recent travel. At presentation, his best corrected vision was count fingers. Examination findings were documented as bilateral eyelid swelling with mucus discharge, thickened erythematous conjunctiva and corneal epithelial defects of 5.5mm x 5mm covered with a gelatinous grey plaque. Investigations were positive for Acidovorax Sp on PCR. Histopathological analysis of the tissue sample demonstrated normal Bowman’s layer and epithelium. Pentacam corneal topography readings were atypical, simply demonstrating an irregular astigmatic pattern. The pre-operative Casia anterior segment optical coherence topography demonstrated a thickened area of epithelium and sub-epithelial area of 111 and 162 microns right and left eye respectively. The patient underwent right then left EDTA-assisted superficial keratectomy with amniotic membrane graft. He was treated with gentamicin 1.5% forte, moxifloxacin 0.5%, and dexamethasone 0.1% eye drops (all no preservative), to both eyes. Once the ocular inflammation had quietened and infection had cleared, the residual sub-epithelial scarring was treated with sequential bilateral phototherapeutic keratectomy with mitomycin C treatment. His vision improved to 6/24 OD, 6/12 OS, 6 months after initial presentation. The growth of Acidovorax Sp promoted us to further explore this gentleman’s history. Interestingly, he remarked that he is an avid watermelon connoisseur, buying a minimum of 15 watermelons a year direct from the farm. In order to check the ripeness and the health of the fruit, he would bring it up to his face and ballot it, and at times the watermelon would rub his eyes. The period when he developed these ocular symptoms, coincided with the watermelon peak season.

Conclusion/Take Home Message:

Ours is the first reported case of acquired sporadic infectious keratopathy in an otherwise healthy gentleman related to contamination from Acidovorax, a devastating fruit blotch from watermelon fruit. The likely proposed mechanism is a toxic acute keratoconjunctivitis with the infection confined to the sub-epithelial area. Whilst rare, successful management can be achieved through a combination of intensive topical antibiotics, superficial keratectomy and surface laser.

Financial Disclosure:

None