Severe Achromobacter xylosoxidans keratitis with deep corneal involvement

To describe a case of Achromobacter xylosoxidans keratitis with deep involvement of the corneal stroma and discuss its management.

A 73 year-old monocular male with infectious keratitis of the right eye was referred to the Wilmer Eye Institute after a month of empiric treatment with besifloxacin. On presentation, slit lamp examination of the right eye demonstrated a diffusely edematous cornea with three areas of corneal infiltrates and an overlying epithelial defect and a 1.3 mm hypopyon in the anterior chamber. The corneal culture performed grew A. xylosoxidans. Empiric antibiotic regimen was adjusted once corneal culture susceptibility results were available. Seven days later, slit lamp examination demonstrated a resolving epithelial defect, stable infiltrates, and resolution of the hypopyon. After approximately two months of follow up with his primary ophthalmologist, he was noted to have recurrent hypopyon and infiltrates and was referred back to Wilmer. Slit lamp examination again demonstrated an epithelial defect, diffuse corneal haze, deep stromal infiltrates, and a 1 mm hypopyon. Corneal infiltrates were too deep to culture. Ultimately, the patient underwent a therapeutic penetrating keratoplasty with anterior chamber washout resulting in improvement of vision.

The indolent progression of A. xylosoxidans keratitis may predispose patients to delayed presentation and treatment. This can result in deep stromal infection that complicates management due to poor antibiotic penetration. Deep stromal infections in A. xylosoxidans keratitis warrant the consideration of intrastromal antibiotic injection or early therapeutic penetrating keratoplasty.