Atopic keratoconjunctivitis complicated by Kocuria koreensis keratitis: the first case
© The Author(s) 2017
Received: 22 September 2016
Accepted: 5 January 2017
Published: 25 January 2017
Patients with atopic dermatitis have a predisposition to Staphylococcus aureus and a Herpes simplex virus infection. The treatment of atopic diseases with steroid and immunosuppressive agents induces opportunistic infection. However, there is a concern regarding visual prognosis in patients with atopic keratoconjunctivitis (AKC) complicated with infectious keratitis. We report an unusual case of an atopic shield ulcer with Kocuria keratitis.
A 51-year-old Japanese man presented with a 14-day history of eye pain and visual loss in his left eye. At the initial examination, a shield ulcer was observed in the upper-central cornea of the left eye, and the conjunctiva in both eyes had a velvety appearance due to papillary formation, as well as hyperemia and swelling in the palpebral area. The shield ulcer showed white stromal opacification in the marginal zone with a coral-like appearance. Samples were obtained by corneal scraping, and Kocuria sp. was identified by microbiological examination including culture and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The 16S rRNA gene sequence analysis was performed using isolated Kocuria strain from the patient. The obtained DNA sequence showed 99% homology with Kocuria koreensis. The combination of corneal scraping and instillation of cefmenoxime antibiotic ophthalmic solution was considered useful for the treatment of Kocuria keratitis.
Clinicians should be aware of Kocuria keratitis as a corneal complication of AKC, and that rapid diagnosis of Kocuria keratitis may improve visual prognosis.
KeywordsAtopic dermatitis Atopic keratoconjunctivitis Kocuria keratitis Shield ulcer
Atopic keratoconjunctivitis (AKC) is a severe chronic allergic conjunctival disease often associated with atopic facial dermatitis. Corneal complications of AKC, including keratoconus, shield ulcer, corneal opacity with neovascularization, and infectious keratitis, impact significantly on the visual prognosis of AKC .
Patients with atopic dermatitis are predisposed to Staphylococcus aureus and Herpes simplex virus skin infections, with potential resultant complications such as contagious impetigo and Kaposi’s varicelliform eruption. Similarly, AKC may be complicated by infectious keratitis such as staphylococcal keratitis and Herpes simplex keratitis (HSK) .
Kocuria spp. are catalase-positive, Gram-positive cocci belonging to the family Micrococcaceae, which comprises 17 species, and are part of the resident flora of the oral cavity and skin. Infectious diseases caused by Kocuria spp. include endocarditis, peritonitis, and catheter-related infections [2–4], and affected individuals are often immunocompromised. Kocuria spp. are also unusual causative organisms in ocular infectious diseases, and there are a small number of reports on Kocuria keratitis [5, 6].
Here, we report the first case of bacterial keratitis caused by Kocuria sp. complicated with a shield ulcer in an AKC patient.
A 51-year-old Japanese man presented with a 14-day history of eye pain and visual loss in his left eye. He was referred to our hospital from a local medical eye clinic for comprehensive investigation of the corneal infection due to lack of response after 7 days to medical treatment for HSK (aciclovir ophthalmic ointment once daily and fluorometholone ophthalmic solution three times daily). His medical history included atopic dermatitis for more than 40 years, AKC with a previous corneal shield ulcer, and HSK recurrence in his left eye 5 years previously.
The scrapings of the corneal ulcer were inoculated into chocolate agar at the initial visit. In addition, polymerase chain reaction for Herpes simplex virus DNA was performed to rule out the possibility of recurrent HSK.
Results of 16S rRNA gene sequence analysis for the isolated strain of Kocuria sp. from the patient
Pairwise similarity (%)
Kocuria koreensis strain P31 16S ribosomal RNA gene, partial sequence
Kocuria carniphila strain CCN 132 16S ribosomal RNA gene, partial sequence
Kocuria rhizophila strain TA68 16S ribosomal RNA gene, partial sequence
Kocuria salsicia strain 104 16S ribosomal RNA gene, partial sequence
Kocuria kristinae strain DSM 20032 16S ribosomal RNA gene, partial sequence
Kocuria halotolerans strain YIM 90716 16S ribosomal RNA gene, complete sequence
Kocuria marina strain KMM 3905 16S ribosomal RNA gene, partial sequence
Kocuria gwangalliensis strain SJ2 16S ribosomal RNA gene, partial sequence
Nesterenkonia lutea strain YIM 70081 16S ribosomal RNA gene, partial sequence
Kocuria indica strain NIO-1021 16S ribosomal RNA gene, partial sequence
Antimicrobial susceptibility results for the isolated Kocuria sp.
Minimum inhibitory concentration (μg/mL)
We report a rare case of Kocuria koreensis keratitis complicated with a shield ulcer in an AKC patient. In cases of opportunistic corneal infection complicating AKC, we should consider the possibility of Kocuria spp., in addition to Staphylococcus aureus and Fungus as causative organisms [7–9], because these species are also considered one of the resident skin flora.
Patients with atopic dermatitis are susceptible to developing skin infections due to alterations in the normal flora, compromised host immunological mechanisms caused by atopic diathesis, and immunosuppression due to administration of certain medications such as steroids and immunosuppressive agents [1, 10]. Staphylococcus aureus populations in the resident flora of the skin increase in patients with atopic dermatitis due to reduced antimicrobial peptides, such as human beta-defensin-2 [1, 11, 12]. In chronic AKC patients, Staphylococcus aureus colonization of the lid margins may exacerbate the allergic inflammatory reactions in the conjunctiva and cornea, thereby facilitating the development of infectious keratitis. In addition, the use of steroid or other immunosuppressive ophthalmic medications in these patients may predispose them to the development of opportunistic infection. Recognized types of infectious keratitis in AKC patients include staphylococcal keratitis and fungal keratitis [7–9].
The characteristic clinical finding in Kocuria keratitis is an echinulate white corneal opacity. Hence, we described the cornea as having a “coral-like appearance” in this case. A case of Kocuria keratitis reported by Mattem et al.  exhibited corneal opacity with a coral-like appearance, similar to our case. Therefore, this coral-like appearance may be considered a useful diagnostic sign.
In this case, microbiological diagnosis was performed using MALDI-TOF/MS. Identification of Kocuria spp. has been performed previously using an automated instrument for identification and antibiotic susceptibility testing (VITEK® 2 system)  or 16S ribosomal DNA sequencing . In our diagnostic method for bacterial keratitis, an abrasion sample of infected cornea is applied directly to chocolate agar and cultured, and species of isolated bacteria are identified using MALDI-TOF/MS. Since diagnosis of the bacterial strain and antimicrobial susceptibility testing can be provided simultaneously, these combination of diagnostic method are considered useful for the rapid diagnosis of rare bacterial keratitis cases. Furthermore, The 16S rRNA gene sequence analysis was performed using isolated Kocria strain from the patient. The obtained DNA sequence showed 99% homology with Kocuria koreensis. Kocuria koreensis is a rare species in causative organism of infectious disease by Kocuria spp. A phylogenetic analysis based on the 16S rRNA gene sequence indicated that Kocuria koreensis P31T was most closely related to Kocuria kristinae DSM 20031T, with 96.9% similarity, and these two strains clustered together in constructed phylogenetic trees . To the best of our knowledge, this is a first report of Kocuria koreensis keratitis.
The Kocuria koreensis isolated from the corneal shield ulcer in this case showed susceptibility to penicillin and a first-generation cephalosporin antimicrobial agent. Therefore, in this case, the combination therapy of corneal scraping and instillation of the cefmenoxime antibiotic ophthalmic solution was considered effective for Kocuria keratitis. However, further investigation on the selection of antibiotics for Kocuria spp. isolated from corneal ulcer is needed.
To the best of our knowledge, this is the first case report of infectious keratitis caused by Kocuria koreensis complicating a shield ulcer in an AKC patient. Precise strain diagnosis and accurate determination of the antimicrobial susceptibility to unusual organisms causing bacterial keratitis are important for the effective treatment of keratitis. In conclusion, clinicians should be aware of Kocuria keratitis as a corneal complication of AKC, and that rapid diagnosis of Kocuria keratitis may improve the visual prognosis.
Herpes simplex keratitis
matrix-assisted laser desorption/ionization time-of-flight mass spectrometry
NI analyzed the data and prepared a draft of manuscript. NI and JS conceived the experiments, and SY edited the manuscript. All authors read and approved final manuscript.
We wish to thank Mrs. Michiko Yagoshi (Nihon University Itabashi Hospital) for her expert technical assistance.
The authors declare that they have no competing interests.
Availability of data and materials
All data generated or analysed during this study are included in this published article.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report.
Ethics approval and consent to participate
Written and oral informed consent to participate has been obtained from the patients and stored in the case files and may be requested to see a copy at any stage.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study was conducted as part of our routine work.
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