대한안과학회지 2016 년제 57 권제 6 호 J Korean Ophthalmol Soc 2016;57(6):999-1003 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2016.57.6.999 Case Report 백내장수술후발생한스타필로코쿠스루그두넨시스안내염 1 예 A Case of Staphylococcus lugdunensis Endophthalmitis after Cataract Surgery 한상윤 이태곤 Sang Youn Han, MD, Tae Gon Lee, MD, PhD 건양대학교의과대학김안과병원안과학교실명곡안연구소 Myunggok Eye Research Center, Department of Ophthalmology, Kim s Eye Hospital, Konyang University College of Medicine, Seoul, Korea Purpose: To report a case of Staphylococcus lugdunensis endophthalmitis following cataract extraction and intraocular lens implantation. Case summary: A 59-year-old woman presented with unilateral vision impairment and eyeball pain in her left eye, thirteen days after phacoemulsification and posterior chamber intraocular lens implantation. Best-corrected visual acuity of her left eye was 20/200. Slit lamp examination of her left eye revealed a severe conjunctival injection, severe chamber reactions with exudative membranes, hypopyon (about 1 mm) in the anterior chamber, and the fundus was not visible. Before the patient was admitted to the hospital, we cultured samples of aqueous fluid and performed an intravitreal antibiotics injection (vancomycin 1.0 mg/0.1 ml, ceftazidime 2.0 mg/0.1 ml). However, on the next day, because the inflammatory reactions of the anterior chamber and vitreous cavity were not improved and Gram positive cocci was confirmed, we performed a pars plana vitrectomy and an additional intravitreal antibiotics injection (vancomycin 1.0 mg/0.1 ml, dexamethasone 0.5 mg/0.1 ml). Seven days after the surgery, Staphylococcus lugdunensis was identified in the aqueous fluids culture. 11 days after the surgery, her inflammation and symptoms were improved and therefore, she could be discharged. Three months after the surgery, best-corrected visual acuity of her left eye was 20/20 and there was no evidence of recurrence of endophthalmitis and no abnormal findings in her fundus. J Korean Ophthalmol Soc 2016;57(6):999-1003 Keywords: Cataract surgery, Endophthalmitis, Postoperative endophthalmitis, Staphylococcus lugdunensis 안내염은백내장수술후에생길수있는매우심각한합병증중의하나로, 적절한치료에도불구하고영구적인시력손상을초래할수있다. 백내장수술후안내염의발생률은 0.05-0.68% 로보고되고있으며, 이를성공적으로치료하기위해서는조기에원인균을동정하고치료하는것이중요하다. 1-3 백내장수술후발생하는안내염중에서원인균이동정된경우는 44-75% 로보고되었고, 4 이중 Staphylococcus Received: 2015. 7. 3. Revised: 2015. 9. 9. Accepted: 2015. 10. 29. Address reprint requests to Tae Gon Lee, MD, PhD Kim's Eye Hospital, #136 Yeongsin-ro, Yeongdeungpo-gu, Seoul 07301, Korea Tel: 82-2-2639-7811, Fax: 82-2-2639-9214 E-mail: idoc@kimeye.com epidermidis, Staphylococcus aureus, Streptococcus species 같은그람양성균이가장흔하며, Psuedomonas, Haemophilus 와같은그람음성균도약 6% 를차지한다. 5 Staphylococcus lugdunensis는그람양성균으로, 눈꺼풀에존재하는정상세균총중의하나이며공기중의오염물, 오염된세척액이나수술도구, 인공수정체, 눈꺼풀과눈물낭의염증등에의해서안내염의원인균이될수있다. 6 S.lugdunensis에의한백내장수술후안내염은매우드물고예후가좋지않은것으로알려져있으며, 국내에서는아직보고된적이없는데, 저자들은백내장수술후 S.lugdunensis에의해발생한안내염 1예에서, 조기에유리체절제술및유리체강내항생제주입술로치료하여좋은결과를경험하였기에, 이를문헌고찰과함께국내처음으로보고하고자한다. c2016 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 999
- 대한안과학회지 2016 년제 57 권제 6 호 - 증례보고 특별한내과적과거력과외상력이없는 59세여자환자가본원에서좌안초음파수정체유화술및인공수정체후낭삽입술을시행받은지 13일째되는날아침부터발생한좌안의통증과시력저하를주소로내원하였다. 백내장수술당시후낭파열등의특이소견은없었다. 내원당시측정한최대교정시력은우안 20/20, 좌안 20/200이었고, 비접촉식안압계로측정한안압은우안 10 mmhg, 좌안 11 mmhg였다. 세극등현미경검사에서좌안의결막충혈, 전방내다수의염증세포 (+4), 1 mm 가량의전방축농과삼출성막이관찰되었다. 매질의혼탁으로인해시신경유두의경계부및안저를관찰하기어려웠으나, 안저반사는비교적잘관찰되었다. 임상적인소견에따라, 백내장수술후발생한안내염으로진단하고입원치료를권유하였다. 입원전전방천자를시행하여그람염색, 세균배양, 진균배양및세균동정검사를의뢰하였고, 유리체강내항생제주입술 (vancomycin 1.0 mg/0.1 ml, ceftazidime 2.0 mg/0.1 ml) 을함께시행하였다. 경구용항생제로 ofloxacin 100 mg tid를처방하였고, 국소점안제로는 0.5% moxifloxacin 점안액과 1% prednisolone acetate 점안액을 2시간간격으로, 1% cyclopentolate HCl 점안액을하루 2차례쓰도록처방하였다. 다음날, 그람양성구균으로보이는균주의증식이다수관찰 A 되었고, 좌안의전방및안저상태에도호전이없어, 국소마취로 23게이지유리체절제술을시행하였다. 백내장수술당시만들었던각막절개창과는다른부위에절개창을내고전방내로접근하여, 동공및후낭인공수정체를덮고있는염증막을 hook과 intraocular forceps를이용하여제거하고, 유리체절제술을시행하였다 (Fig. 1). 수술중망막박리, 망막괴사, 망막출혈등안저의특별한이상소견은관찰되지않았고, 안저의염증물질과혼탁을최대한제거하였다 (Fig. 2). 수술을마치면서 vancomycin 1.0 mg/0.1 ml, dexamethasone 0.5 mg/0.1 ml를유리체강내로주사하였으며, 수술후처방으로전신적항생제 (vancomycin 500 mg IV bid) 투여를시작하였다. 수술후 2일째, 전방축농이사라지고전방내염증은호전되었지만, 유리체강이다시혼탁해지는것으로보여유리체강내항생제주입술 (vancomycin 1.0 mg/0.1 ml) 을한차례더시행하고 5% vancomycin 점안액도 1일 6회추가처방하였다. 수술후 7일째, 좌안의최대교정시력은 20/70으로개선되었고전방및유리체강내염증은호전되었으며, 안저에서도특별한이상소견은관찰되지않았고, 주관적인증상도많이호전되었다. 같은날, 균배양검사결과 Staphylococcus lugdunensis가동정되었고, 항균제감수성검사결과 ciprofloxacin, gentamycin, vancomycin 등대부분의항균제에감수성이있었다 (Table 1). 이를토대로전신적 vancomycin의투여를중단하고, 경구용항생제를 ofloxacin 100 mg tid에서 ciprofloxacin 250 mg bid로변경하였으며, 0.5% moxifloxacin 점안액과 5% vancomycin 점안액을 1일 4회점안하도록하였다. 수술후 11 B Figure 1. Pre- and intraoperative findings. (A) Just before vitrectomy, anterior segment shows severe conjunctival injection and hypopyon. (B) Thick, exudative membranes were found in anterior chamber. Figure 2. Intraoperative fundus finding. At the end of vitrectomy, there was no inflammation or retinal hemorrhages on her left fundus. 1000
- 한상윤 이태곤 : 스타필로코쿠스루그두넨시스안내염 - Table 1. The result of antibiotic sensitivity test of Staphylococcus lugdunensis Antibiotics Sensitivity Ciprofloxacin Clindamycin Erythromycin Fusidic acid Gentamycin Habekacin Linezolid Nitrofurantoin Oxacillin Penicillin G Resistant Quinupristin/dalfopristin Rifampin Teicoplanin Telithromycin Tetracycline Resistant Trimethoprim/sulfamethoxazole Vancomycin Figure 3. Postoperative fundus finding. At 3 months after vitrectomy, there was no inflammation or infection signs on fundus photo. 일째, 상기와같은치료로전방및유리체강내염증과주관적증상이지속적으로호전되어퇴원하였으며, 수술후 3개월째경과관찰당시좌안의최대교정시력은 20/20으로회복되었고, 안내염의재발및안저의이상소견은관찰되지않았다 (Fig. 3, 4). 고 찰 초음파수정체유화술및인공수정체후낭삽입술은안과영역에서가장흔하게행하는수술중하나이며, 백내장수술후발생하는안내염은영구적인시력손상가능성은물론적절한치료후에도시력예후가좋지않은것으로알려 Figure 4. Anterior segment photography. Anterior segment photography on 3 months postoperative day shows clear cornea, normal anterior chamber, and posterior capsular intraocular lens was in place. 진심각한합병증중하나이다. 1,2 안내염의치료결과를좋게하기위해서는빠른진단과적절한치료를통해서균의독소에의한안내조직의손상을최소화해야한다. 4 안내염을일으키는흔한원인균과항균제감수성대해서아는것은초기의경험적치료방침을결정하는데중요하기때문에, 여러연구자들이이에대해보고하였다. 1997년발표된 Endophthalmitis Vitrectomy Study 7 에따르면백내장수술후발생한안내염환자의검체에서 Coagulase negative staphylococci (CNS, 70.0%) 가가장많이자랐고, S.aureus (9.9%), Viridans streptococci (3.7%), S.pneumonia (2.2%) 의순서를보였다. CNS 가운데는 S.epidermidis (81.9%) 가가장많았고, S.lugdunensis (5.9%), S.warneri (2.7%) 순이었다. CNS에대한항균제감수성검사에서는 Amikacin (86.1%), Vancomycin (100.0%) 이높은감수성을보였으며, 그람음성균에의한감염에서많이사용되는항생제인 Ceftazidime (62.1%) 은낮은감수성을보였다. 6,8 Kunimoto et al 9 은 206명 206안의수술후안내염환자를대상으로연구하여총 112안에서원인균주를동정하였는데, 이중 S.epidermidis (33.3%) 가가장많았으며, Pseudomonas species (19.8%), Aspergillus species (13.5%) 순이었다고보고했다. CNS에대한항균제감수성검사에서는 Cefazolin (93.2), Amikacin (89.5%), Ciprofloxacin (88.4%), Vancomycin (86.8%), Ceftazidime (80.8%) 모두 80% 이상의감수성을보였다. S.lugdunensis는 CNS의일종으로, 주로피부와연조직염증의원인균으로알려져있으며뇌농양, 뇌수막염, 패혈 1001
- 대한안과학회지 2016 년제 57 권제 6 호 - 증, 만성골수막염, 심내막염, 비뇨기계감염, 창상감염등도일으킬수있다. 10 S.lugdunensis는눈꺼풀에도존재하기때문에안구의침습적인수술이나시술시안구내로이환되어안내염을일으킬가능성도있다. 6 S.lugdunensis는배양검사에서황색의색소침착을보이며, 혈액배지에서완전용혈되는특징이있는데이는 S.aureus의형태학적인특징과비슷하기때문에정확히구분하기가까다롭다. 따라서 S.lugdunensis 의정확한판별을위해서는일반적인배양검사와 ornithine decarboxylase, pyrrolidonyl arylamidase phenotypic test 같은생화학적인검사, eubacterial polymerase chain reaction amplification (PCR) 을함께시행하는것이도움이될수있다. 11 S.lugdunensis 감염증은다른종의 Staphylococcus 감염에비해서독성이강한데, 이는 S.lugdunensis가만들어내는세포외독소나당질층이중성구에의한탐식작용이나효소의생산을방해하기때문이다. 10 Chiquet et al 11 은백내장수술후에발생한 S.lugdunensis 안내염 5예에대해서보고하였다. 이들이백내장수술후안내염으로진단받기까지의기간은평균 7.6일 ( 범위 5-12일 ) 이었으며, 이중 3예에서일차유리체절제술후망막박리가발생하여이차유리체절제술을필요로하였고이 3예는모두최종시력이안전수동이하였다. 이를토대로, Chiquet et al 11 은다른 CNS에의한안내염에비해 S.lugdunensis에의한안내염이최종적인시력예후가더나빴으며, 유리체절제술후망막박리가생길확률도높다고했고, 이는 S.lugdunensis의독성이후극부뿐만아니라망막의주변부까지망막조직의괴사와같은손상을유발하는것과연관이있는것같다고하였다. 본증례에서는입원전전방천자와함께유리체강내항생제주입술을시행하였으나염증이곧바로좋아지지는않았고, 입원다음날조기에유리체절제술을시행하여후낭인공수정체주변및전방내의염증물질, 유리체강의혼탁을최대한제거하고전신적항생제치료를시작하면서염증이줄어들고시력이회복됨을확인하였다. 본증례의최종시력은 20/20으로좋았고, 수술후에도망막박리등의합병증이발생하지않았는데, 이는진단당시초기시력이 20/200으로비교적좋았던점과입원다음날조기에유리체절제술을시행하여감염균과독소를없애고, S.lugdunensis의독성으로인한안내조직의손상을최소화하였던점때문일것으로생각한다. Han et al 8 과 Kunimoto et al 9 의연구에서 CNS에의한안내염은그람양성구균감염에널리쓰이는경험적항생제에비교적높은감수성을갖는것으로보고하였다. 본증례에서도초기배양검사에서그람양성구균이 보고되어경험적으로 vancomycin 점안액과 vancomycin 정맥주사를추가처방하였으며, 이또한염증을호전시키는데중요한역할을했을것으로생각된다. 요약하면, S.lugdunensis는눈꺼풀의정상세균총을이루는균주중하나로안내염을유발할수있고, 독성이강하므로신속하게배양검사및균동정검사를시행해야하며, 그람양성구균이자랄경우드물지만 S.lugdunensis 안내염의가능성도고려해야한다. 백내장수술후발생한 S.lugdunensis 안내염을적절한국소적, 전신적그리고유리체강내항생제주입술과조기유리체절제술로치료한 1예를경험하였기에이를보고하는바이다. REFERENCES 1) Lalwani GA, Flynn HW JR, Scott IU, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology 2008;115:473-6. 2) Doft BH, Kelsey SF, Wisniewski S, et al. Treatment of endophthalmitis after cataract extraction. Retina 1994;14:297-304. 3) Laatikainen L, Tarkanen A. Early vitrectomy in the treatment of post-operative purulent endophthalmitis. Acta Ophthalmol (Copenh) 1987;65:455-60. 4) Jung JY, Ko BY, Kim BY. Factors associated with a poor visual result in acute endophthalmitis after cataract surgery. J Korean Ophthalmol Soc 2008;49:1242-7. 5) Han YS, Chung IY, Park JM. A case of Alcaligenes xylosoxidans endophthalmitis after cataract extraction. J Korean Ophthalmol Soc 2005;46:186-9. 6) Bannerman TL, Rhoden DL, McAllister SK, et al. The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study. A comprarison of eyelid and intraocular isolates using pulsedfield gel electrophoresis. Arch Ophthalmol 1997;115:357-61. 7) Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479-96. 8) Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol 1996;122:1-17. 9) Kunimoto DY, Das T, Sharma S, et al. Microbiologic spectrum and susceptibility of isolates: part I. postoperative endophthalmitis. Endophthalmitis Research Group. Am J Ophthalmol 1999;128: 240-2. 10) von Eiff C, Peters G, Heilmann C. Pathogenesis of infections due to coagulase-negative staphylococci. Lancet Infect Dis 2002;2:677-85. 11) Chiquet C, Pechinot A, Creuzot-Garcher C, et al. Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis. J Clin Microbiol 2007;45:1673-8. 1002
- 한상윤 이태곤 : 스타필로코쿠스루그두넨시스안내염 - = 국문초록 = 백내장수술후발생한스타필로코쿠스루그두넨시스안내염 1 예 목적 : 백내장수술후발생한 Staphylococcus lugdunensis 안내염 1 예를경험하였기에이를보고하고자한다. 증례요약 : 59 세여자환자가본원에서좌안백내장수술을받은후 13 일째발생한좌안의통증과시력저하를주소로내원하였다. 좌안의최대교정시력은 20/200 이었고, 세극등현미경검사에서좌안의결막충혈, 전방내다수의염증세포, 1 mm 가량의전방축농과삼출성막이관찰되었으며안저는흐려잘보이지않았다. 전방천자및유리체강내항생제주입술 (vancomycin 1.0 mg/0.1 ml, ceftazidime 2.0 mg/0.1 ml) 을시행하고입원하였는데, 다음날증상의호전이없고그람양성구균이자라는것이확인되어, 유리체절제술과함께유리체강내항생제주입술 (vancomycin 1.0 mg/0.1 ml, dexamethasone 0.5 mg/0.1 ml) 을추가로시행하였다. 수술 7 일째, 균배양검사결과 Staphylococcus lugdunensis 가동정되었고, 수술 11 일째, 염증이조절되고증상이호전되어퇴원하였다. 수술 3 개월후, 좌안의최대교정시력은 20/20 이며, 안내염의재발및안저의이상소견은관찰되지않았다. < 대한안과학회지 2016;57(6):999-1003> 1003