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中华眼科医学杂志(电子版)

中华眼科医学杂志(电子版) ›› 2024, Vol. 14 ›› Issue (02) : 90 -94. doi: 10.3877/cma.j.issn.2095-2007.2024.02.005

病例报告

儿童角膜二氧化碳嗜纤维菌感染1例
黄小雨1, 王玮1, 徐玲娟1, 陈丽雯1, 高晶1, 李贵刚1,†()   
  1. 1. 430030　武汉，华中科技大学同济医学院附属同济医院眼科
  • 收稿日期:2024-03-22 出版日期:2024-04-28
  • 通信作者: 李贵刚
  • 基金资助:
    国家自然科学基金面上项目(82070936); 湖北省卫健委2022年立项课题(WJ2021ZH0005); 湖北省科技厅高端外国专家类项目(2022EGD020)

One case of corneal carbon dioxide fiber optic bacterial infection in children

Xiaoyu Huang, Wei Wang, Lingjuan Xu   

  • Received:2024-03-22 Published:2024-04-28
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黄小雨, 王玮, 徐玲娟, 陈丽雯, 高晶, 李贵刚. 儿童角膜二氧化碳嗜纤维菌感染1例[J]. 中华眼科医学杂志(电子版), 2024, 14(02): 90-94.

Xiaoyu Huang, Wei Wang, Lingjuan Xu. One case of corneal carbon dioxide fiber optic bacterial infection in children[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2024, 14(02): 90-94.

患儿，男性，5岁5个月。患儿因右眼被猫抓伤1 d，眼结膜充血、眼痛及视物不清，于2023年8月23日至华中科技大学同济医学院附属同济医院眼科就诊。SL－40H型裂隙灯显微镜(英国KEELER公司生产)检查结果显示右眼混合充血，角膜全层裂伤。给予完善全身检查、注射狂犬疫苗，收入院。患儿既往足月顺产，出生时体重正常，无吸氧史，既往无眼部疾病史和其他疾病史。右眼视力指数/20 cm，左眼视力1.0；双眼眼压均为12 mmHg(1 mmHg＝0.133 kPa)。右眼眼睑肿胀，结膜混合性充血，下方角膜可见弧形全层裂伤，伴有虹膜嵌顿，前房浅，瞳孔变形，晶状体混浊，其余窥不入；左眼无充血，角膜透明，前房清晰，瞳孔直径3 mm，对光反射灵敏，晶状体透明，眼底未见明显异常。诊断为右眼角膜穿通伤，右眼外伤性白内障。遂于当日急诊全身麻醉下行右眼角膜穿通伤清创缝合术联合前房冲洗及前房成形术。术中见角膜中央全层裂伤，伤口长度约4.5 mm，伴有虹膜嵌顿于伤口且部分脱出、坏死。经专家组讨论，切除部分坏死虹膜，还纳嵌顿虹膜，在黏弹剂辅助下采用10－0尼龙线间断缝合角膜全层，达到水密状态。手术过程顺利无并发症，术中未见晶状体皮质外溢，因此未行白内障摘除手术。术后给予右眼1%醋酸泼尼松龙滴眼液(爱尔兰艾尔建制药公司生产)点眼，4次/d；0.5%盐酸莫西沙星滴眼液(华润紫竹药业有限公司生产)点眼，3次/d；重组牛碱性成纤维细胞生长因子眼用凝胶(珠海亿胜生物制药有限公司生产)点眼，3次/d；0.5%复方托吡卡胺滴眼液(沈阳兴齐制药有限公司生产)点眼，1次/晚；头孢克洛干混悬剂[亿腾医药(苏州)有限公司生产]口服，0.125 g，3次/d。术后3 d患儿病情稳定，无明显眼部疼痛。右眼视力指数/40 cm，眼压正常，角膜上皮愈合良好，裂伤口对合好，缝线无松脱，前房深度正常，房水闪辉阳性，瞳孔欠圆，直径约3 mm，颞下方虹膜部分缺损，晶状体混浊，眼底结构不清。见图1。遂嘱带药出院，定期复查。7 d后复诊，右眼视力指数/30 cm；术后20 d复诊右眼视力0.3。角膜伤口未见明显感染迹象，缝线未见松动。2023年10月3日，在角膜手术后40 d，患儿因"右眼流泪不能睁眼4 d"再次就诊。给予0.5%盐酸丙美卡因(美国爱尔康公司生产)表面麻醉下裂隙灯显微镜检查。见图2A和图2B。经裂隙灯显微镜检查，可见角膜中央灰白色浸润灶，直径约3 mm×4 mm,位于伤口内角膜深基质层，房水闪辉阳性，未见前房积脓，SW－2100型眼部B型超声(天津市索维电子技术有限公司生产)检查未见后节感染迹象。考虑患儿为感染性角膜炎，细菌性感染可能性大，遂予以局部加强抗感染及促进修复治疗，给予右眼0.5%左氧氟沙星滴眼液(扬子江药业集团有限公司生产)点眼，1次/2 h；0.3%妥布霉素滴眼液(美国爱尔康公司生产)点眼，1次/2 h；盐酸左氧氟沙星眼用凝胶(湖北远大天天明制药有限公司生产)点眼，1次/晚；0.1%普拉洛芬滴眼液(日本千寿制药株式会社生产)点眼，4次/d；重组牛碱性成纤维细胞生长因子眼用凝胶，2次/d。药物治疗3 d后角膜感染未见明显好转，患儿眼痛和视物不清症状未缓解。经裂隙灯显微镜检查，可见角膜浸润病灶直径约4 mm×4 mm，病灶有扩大趋势，前房少量积脓，眼部B型超声检查未见后节感染迹象。为防止感染进一步加重导致眼内炎，经病例讨论，与家属交流，取得对方同意后遂于2023年10月7日急诊全身麻醉下行右眼同种异体穿透性角膜移植术。见图3A和3B，术中选取植床直径7.5 mm，植片直径7.75 mm。术后右眼给予0.1%他克莫司滴眼液(日本千寿制药株式会社生产)点眼，2次/d；0.1%普拉洛芬滴眼液点眼，4次/d；重组牛碱性成纤维细胞生长因子眼用凝胶点眼，2次/d；0.5%复方托吡卡胺滴眼液点眼，1次/晚；0.5%左氧氟沙星滴眼液点眼，4次/d；盐酸左氧氟沙星眼用凝胶点眼，1次/晚。术中所取感染角膜分别送一般细菌培养、一般真菌培养及病原微生物高通量二代测序检测与鉴定。病原学检查结果显示，28℃和35℃条件下一般细菌及真菌培养均为阴性。病原微生物高通量基因检测覆盖革兰氏阳性细菌、革兰氏阴性细菌、分枝杆菌、支原体、衣原体及立克次体等10 989种细菌,脱氧核糖核酸病毒和核糖核酸病毒等5050种病毒，1179种真菌及282种寄生虫。提示为二氧化碳嗜纤维菌属和口炎二氧化碳嗜纤维菌种阳性，检出序列5，相对丰度1.08%。真菌、病毒、寄生虫、结核分枝杆菌、支原体、衣原体及立克次体等均未检出。另有检出痤疮丙酸杆菌，但相对丰度0.33%较低，且为常见眼表定植菌。综合患儿被猫抓伤病史及临床表现，诊断患儿为二氧化碳嗜纤维菌感染。术后患儿恢复良好，定期复查。治疗10个月余后，患儿右眼视力恢复至0.1，眼压12 mmHg，角膜植片透明，缝线未松脱，未见植片排斥及感染复发，内皮细胞密度1932个/mm2。见图4。

图1　二氧化碳嗜纤维菌感染性角膜炎患者"右眼角膜穿通伤清创缝合术联合前房冲洗及前房成形术"术后2 d右眼眼前节彩色照相　可见结膜轻度充血，角膜伤口对合良好，伤口附近角膜轻度水肿　 图2　二氧化碳嗜纤维菌感染性角膜炎患者术后40 d右眼影像　图2A示眼前节彩色照相，可见右眼混合充血，角膜中央、伤口层间均可见灰白色浸润灶，伴有部分缝线松动；图2B示右眼眼前节光学相干断层扫描成像，可见角膜伤口处角膜水肿，感染累及角膜全层　 图3　二氧化碳嗜纤维菌感染性角膜炎患者角膜手术后43 d行右眼同种异体穿透性角膜移植术术前术后眼前节彩色照相　术中植片直径7.75 mm，植床直径7.5 mm，完整切除病灶　图3A示术前眼前节彩色照相；图3B示术后眼前节彩色照相　 图4　二氧化碳嗜纤维菌感染性角膜炎患者穿透性角膜移植术后10个月余的眼前节彩色照相　患者视力0.1，可见右眼结膜无充血，角膜植片透明，部分缝线已拆除，其余角膜缝线在位，未见感染复发及排斥反应
表1 眼部二氧化碳嗜纤维菌属感染的文献汇总
第一作者 地区 发表年份 病例数 菌种 鉴定方式 临床表现 手术及结局
Yang等[2] 美国 2021 1 C.canimorsus 脱氧核糖核酸测序 滤过泡感染 清创联合巩膜修补，视力20/70
Chodosh等[6] 美国 2001 1 C.canimorsus 细菌培养 角膜溃疡 角膜刮片，视力20/30
de－Smet等[7] 美国 1990 1 未鉴定 细菌培养 角膜溃疡 角膜清创，视力20/30
Oshida等[8] 日本 2011 1 未鉴定 细菌培养 角膜穿孔，暴发性脉络膜出血 摘除眼球
Wilson等[9] 美国 1998 1 未鉴定 细菌培养 义眼座植入后眼窝感染 义眼座取出
Ghosheh等[10] 美国 2007 1 未鉴定 细菌培养 角膜溃疡 角膜刮片，视力20/100
Ticho等[11] 美国 1990 1 未鉴定 细菌培养 角膜溃疡 角膜清创，视力20/50
Muen等[12] 苏格兰 2009 1 与C. cynodegmi 88%同源 聚合酶链反应法 双侧眼内炎 双眼晶体摘除加玻璃体切除，双眼视力20/40
Wolfram等[13] 德国 2024 1 C. felis Sanger测序 眼内炎 玻璃体切除联合白内障手术，视力1.0
Font等[14] 美国 1994 3 C.Ochracea 细菌培养和电子显微镜检查 角膜溃疡 角膜移植术，3例术后角膜植片均透明
Phipp等[15] 澳大利亚 2002 1 C.canimorsus 细菌培养 眼内炎 玻璃体抽液及抗生素注射，视力6/60
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