Endophthalmitis associated with fungal keratitis and penetrating injuries in North China.

PURPOSE: To report the laboratory findings, management strategies, and visual outcomes of culture-proven exogenous fungal endophthalmitis in North China. METHODS: The microbiological and treatment records of patients with culture-positive exogenous fungal endophthalmitis who visited the Affiliated Hospital of Qingdao University from January 2012 to December 2016 were reviewed. RESULTS: A total of 39 eyes (39 patients) were identified over a 5-year period. Exogenous fungal endophthalmitis was associated with penetrating trauma in 22 eyes (56.4%), fungal keratitis in 15 eyes (38.5%), and intraocular surgery in 2 eyes (5.1%). Hyphae were found in 29 of 37 smear samples (78.4%) by direct microscopic examination. Fungal pathogens cultured from 39 samples were identified as 10 genera and 15 species. Filamentous fungi (molds) accounted for 94.9% (37 samples), including Fusarium (19, 48.7%) and Aspergillus (11, 28.2%). Most keratitis cases were caused by Fusarium (11 of 15; 73.3 %). Aspergillus was isolated from nine penetrating ocular trauma cases (9 of 22; 40.9%). Three eyes receiving evisceration had fungal and bacteria coinfection (3 of 39, 7.7%) with Aspergillus and Bacillus. At least, one surgical intervention was performed in all 39 eyes and 28 (71.8%) eyes underwent two or more procedures, including surgeries and intraocular injections. Twenty-nine patients received intraocular antifungal therapy with amphotericin B and/or voriconazole. Visual acuity at discharge from the hospital was significantly better than the initial visual acuity (p < 0.001). Final vision of 20/400 or better was achieved in 22 (56.4%) eyes. CONCLUSIONS: This study highlighted the differences between clinical categories of exogenous fungal endophthalmitis. Trauma was the major etiological factor. Molds were the most common pathogens, with Fusarium ranking first, followed by Aspergillus. Fungal and bacterial coinfection mostly occurred after metal penetrating trauma, and Bacillus was the primary bacterial pathogen. Coinfection may be one reason of evisceration. Immediate intravitreal antifungal therapy combined with vitrectomy was effective for exogenous fungal endophthalmitis. Amphotericin B and voriconazole were commonly used antifungal agents.

Stimulative role of ST6GALNAC1 in proliferation, migration and invasion of ovarian cancer stem cells via the Akt signaling pathway.

BACKGROUND: Ovarian cancer is known as one of the most common cancers in the world among women. ST6GALNAC1 is highly expressed in cancer stem cells (CSCs), which correlates to high tumor-initiating, self-renewal and differentiation abilities. This present study aims to investigate how ST6GALNAC1 affects ovarian cancer stem cells (OCSCs). METHODS: In order to identify the differentially expressed genes related to ovarian cancer, microarray-based gene expression profiling of ovarian cancer was used, and ST6GALANC1 was one of the identified targets. After that, levels of ST6GALNAC1 in OCSCs and ovarian cancer cells were examined. Subsequently, an Akt signaling pathway inhibitor LY294002 was introduced into the cluster of differentiation 90+ (CD90+) stem cells, and cell proliferation, migration and invasion, levels of CXCL16, EGFR, CD44, Nanog and Oct4, as well as tumorigenicity of OCSCs were examined. RESULTS: By using a comprehensive microarray analysis, it was determined that ST6GALNAC1 was highly expressed in ovarian cancer and it regulated the Akt signaling pathway. High levels of ST6GALNAC1 were observed in OCSCs and ovarian cancer cells. Silencing ST6GALNAC1 was shown to be able to reduce cell proliferation, migration, invasion, self-renewal ability, tumorigenicity of OCSCs. In accordance with these results, the effects of ST6GALNAC1 in OCSCs were dependent on the Akt signaling pathway. CONCLUSIONS: When taken together, our findings defined the potential stimulative roles of ST6GALNAC1 in ovarian cancer and OCSCs, which relied on the Akt signaling pathway.

Hypopyon in patients with fungal keratitis.

BACKGROUND: Hypopyon is common in eyes with fungal keratitis. The evaluation of the clinical features, culture results and the risk factors for hypopyon and of the possible correlation between hypopyon and the treatment outcome could be helpful for making treatment decisions. METHODS: The medical records of 1066 inpatients (1069 eyes) with fungal keratitis seen at the Shandong Eye Institute from January 2000 to December 2009 were reviewed retrospectively for demographic features, risk factors, clinical characteristics, laboratory findings and treatment outcomes. The incidence of hypopyon, the fungal culture positivity for hypopyon, risk factors for hypopyon and the effect of hypopyon on the treatment and prognosis were determined. RESULTS: We identified 1069 eyes with fungal keratitis. Of the 850 fungal culture-positive eyes, the Fusarium species was the most frequent (73.6%), followed by Alternaria (10.0%) and Aspergillus (9.0%). Upon admission, 562 (52.6%) eyes with hypopyon were identified. The hypopyon of 66 eyes was evaluated via fungal culturing, and 31 eyes (47.0%) were positive. A total of 194 eyes had ocular hypertension, and 172 (88.7%) of these eyes had hypopyon (P < 0.001). Risk factors for incident hypopyon included long duration of symptoms (P < 0.001), large lesion size (P < 0.001) and infection caused by the Fusarium and Aspergillus species (P < 0.001). The positivity of fungal culture for hypopyon was associated with duration of symptoms and lesion size. Surgical intervention was more common in cases with hypopyon (P < 0.001). Hypopyon was a risk factor for the recurrence of fungal keratitis after corneal transplantation (P = 0.002). CONCLUSIONS: Hypopyon is common in patients with severe fungal keratitis and can cause ocular hypertension. About half of the hypopyon cases were positive based on fungal culture. Long duration of symptoms, large lesion size and infection with the Fusarium and Aspergillus species were risk factors for hypopyon. The presence of hypopyon increases the likelihood of surgical intervention.

[Etiological profiles and pathogen detection of infectious endophthalmitis].

OBJECTIVE: To retrospectively analyze the etiological characteristics of infectious endophthalmitis so as to improve the positive detection rate of its pathogens in laboratory test. METHODS: The epidemiological features and laboratory findings of 319 inpatients (319 eyes) diagnosed with infectious endophthalmitis at our institute from January 2000 to December 2010 were retrospectively reviewed and analyzed. RESULTS: Ocular trauma (n = 230, 72.10%) was a major risk factor for infectious endophthalmitis. Bacteria and fungi were isolated from intraocualr specimens with the positive rates of 43.57% (139/319) and 18.22% (49/269) respectively. The positive rates of bacteria culture were 29.00% for nutrient broth medium and 50.23% for blood enrichment medium respectively. And the difference was statistically significant (χ(2) = 12.58, P < 0.01). The sensitivity of isolated bacteria to levofloxacin was 81.82%. The geometric mean of minimal inhibitory concentrations of amphotericin B, fluconazole, ketoconazole and itraconazole against fungi were 1.05, 5.07, 3.00 and 2.42 µg/ml respectively. CONCLUSION: The major cause of infectious endophthalmitis is ocular trauma and the dominant pathogen is bacteria. The use of blood enrichment medium may improve the positive rate of bacteria culture. Levofloxacin and amphotericin B are indicated for the treatment of bacterial and fungal endophthalmitis.

[Severe fungal corneal ulcer resulting in infectious endophthalmitis].

OBJECTIVE: To analyze causes of serious fungal corneal ulcer resulting in infectious endophthalmitis and explore clinical strategies of avoiding the failure of antifungal therapy. METHODS: Etiological factors, pre-hospital treatments, clinical features and laboratory findings of 47 inpatients with fungal corneal ulcer resulting in endophthalmitis from January 1999 to December 2008 in Qingdao eye hospital were retrospectively reviewed. RESULTS: Rural residents (95.7%) dominated in 47 cases with a mean age of (49.8 ± 10.1) years. Ocular trauma was the leading cause of fungal corneal ulcer (66.0%). Three patients were ever treated with hormone drugs after the fungal infection. Primary, secondary and tertiary hospital accounted for 68.1%, 17.0% and 14.9% among first medical consultation sites. Diagnostic accuracies of fungal corneal ulcer in three grade hospitals were 31.3%, 62.5% and 71.4% respectively. The average interval from the onset of disease to the admission into our hospital was (29 ± 23) days. The dominating pathogen was genus Fusarium (91.5%) with F. solani (48.9%), F. oxysporum (31.9%) and F. moniliforme (8.5%). Antifungal drug sensitivity tests were performed in 21 patients. The first three sensitive drugs were natamycin (88.9%), voriconazole (78.6%) and amphotericin B (61.9%). The first three drug-resistant ones were miconazole (90.5%), fluconazole (66.7%) and itraconazole (61.9%). CONCLUSION: Main causes of fungal corneal ulcer resulting in infectious endophthalmitis included lower diagnostic accuracies of first medical consultation in primary hospitals, abuses of non-sensitive drug and delayed treatment of patients. Improving clinical capabilities of doctors in primary hospitals, emphasizing antifungal drug susceptibility tests, and consummating the social security system and the referral system could be effective measures to avoid therapeutic failures.

[Preliminary study on the use of DNA suspension array for the identification of corneal pathogenic fungi].

OBJECTIVE: To develop a multiplex, microsphere-based DNA suspension array for the identification of important pathogenic fungi of cornea and to study the feasibility of its application in the clinical diagnosis of fungal keratitis. METHODS: Fusarium solani, Fusarium moniliforme, Fusarium oxysporum, Aspergillus fumigatus and Aspergillus flavus, which covered about 80% of pathogenic fungi of fungal keratitis, were chosen as target species of this study. Five species-specific capture probes were designed in the internal transcribed spacer (ITS) regions of ribosomal DNA and synthesized with 5' amino modifier C12 to covalently bind to different sets of fluorescent beads. Biotinylated amplicons of 5 reference strains and 42 clinical strains were generated with a pair of universal primers to yield fragments for detection. Comparison between single species detection and multiplex detection were designed, as well as detection between array and agarose gel electrophoresis (AGE). Spearman rank correlation analysis and t test were applied to evaluate the specificity, sensibility and reproducibility of suspension array. RESULTS: Five reference strains and 40 of 42 (95.2%) clinical strains were correctly identified within 3 h post-PCR amplification while 2 other clinical strains were not identified because of their high background fluorescence intensity. Positive S/B ranged from 5.6 to 13.3. There was no significant difference between respective detection and mixed detection of 5 species (t = 0.2524, P = 0.8132). The sensitivity limit for this assay was determined to be 0.94 ng PCR products. The MFI presented positive correlation with amount of PCR products (r(s) = 1.0000, P < 0.01). Coefficient variation of four repeated detections was 1.8% - 13.7%. CONCLUSION: The suspension array is a rapid, sensitive and specific method for the identification of the most important species of corneal pathogenic fungi and might be used in the clinical laboratories.

[Study of different methods in reducing conjunctival bacteria before cataract surgery].

OBJECTIVE: To study the conjunctival bacteria flora in eyes of patients undergoing cataract surgery and determine the efficacy of reducing conjunctival bacteria with different methods. METHODS: A total of 135 eyes of 135 patients scheduled to undergo cataract surgery were randomized into 3 groups (45 each). They received topical prophylactic treatment with three different kinds of antibiotics (0.5% levofloxacin, 0.3% levofloxacin and 0.3% tobramycin). Each group was randomized into one-day group and three-day group. All the eyes underwent irrigation of fornices with 2.5% povidone-iodine (PVI) before surgery. Conjunctival cultures were obtained at various time points. RESULTS: The total positive rate of conjunctival cultures was 66.7%. The eliminating rate of conjunctival bacteria in one-day groups were 72.7%, 72.7% and 61.1% (P = 0.667) while 70.0%, 70.0% and 55.5% in the three-day groups respectively (P = 0.751). Immediately after PVI irrigation, the eliminating rate in one-day groups added up to 86.4%, 77.3% and 88.9% (P = 0.564) as compared with 90.0%, 80.0% and 66.7% in the three-day groups respectively (P = 0.749). And there was no statistically significant difference between one-day groups and three-day groups in the eliminating rate of conjunctival bacterial after the topical antibiotic application. The MIC test revealed that the antibiotic sensitivity of Gram-positive cocci (G(+)C) to levofloxacin was 94.8% versus 74.1% to tobramycin (P = 0.000) while the antibiotic sensitivity of Gram-negative bacillus (G(-)B) to levofloxacin was 94.4% versus 83.3% to tobramycin (P = 0.289). CONCLUSION: G(+)C accounts for the most among the conjunctival bacteria flora in eyes of patients undergoing cataract surgery and there is no statistically significant difference in the efficacy of reducing conjunctival bacteria between the application of topical antibiotic for one day and for three days. Both G(+)C and G(-)B retain a high sensitivity to levofloxacin. Topical antibiotic in combination with 2.5% PVI irrigation further reduces conjunctival bacteria.

[A pharmacodynamics study of an intravitreal amphotericin B drug delivery system for the treatment of experimental Aspergillus fumigatus endophthalmitis].

OBJECTIVE: To observe a new amphotericin B drug delivery system (AmB-DDS), and investigate the therapeutic effects of AmB-DDS on an experimental Aspergillus fumigatus endophthalmitis. METHODS: (1) In order to observe the effects of AmB-DDS, thirty-four New Zealand albino rabbits were intravitreal injected Aspergillus fumigatus suspension (10(3) colony forming unit, CFU) in applanation of vitreous body before therapy 48 hours. All models were randomly divided into five groups. Group A was the empty control group, treated nothing after Aspergillus fumigatus injection, group B was the empty DDS implantation combined with vitrectomy, no treatment after DDS implanted, group C: AmB 5 microg-injection combined with vitrectomy, the injection was repeated two week later, group D: 250 microg AmB-DDS intravitreal implantation combined with vitrectomy, Group E: 500 microg AmB-DDS intravitreal implantation combined with vitrectomy. Aqueous flare, cells, anterior vitreous cells and vitreous opacity were graded, and vitreous humor smear and culture were performed at different time points after operation in 8 weeks. Two months after operation, light microscopy was used histology evaluation. (2) To observe the release of AmB-DDS in Group H (6 eyes), 500 microg AmB-DDS were implanted in the eye of the rabbits after vitrectomy, vitreous humor was aspirated and the concentrations of amphotericin B were determined by high performance liquid chromatography (HPLC). RESULTS: The inflammation response was lower in groups C, D, E than groups A, B. There was no significant statistical difference between group A and group B (P > 0.05), but differences among C, D, E and groups A, B were significant (P < or = 0.005). The inflammation grade was lower in group E than group C (P < or = 0.005). There was significant statistical difference between the cure effect of group E and group D (chi(2) = 10.494, P = 0.003). All of vitreous humor smears was positive in 1.5 months after surgery, but the culture was only positive in group A, and B. Pathological examination indicated that normal structure was disappeared in the eyes with Aspergillus endophthalmitis. At the first day after surgery, AmB were observed by analysis of HPLC, there was sustained AmB release in the group of AmB-DDS application during the observation periods. CONCLUSIONS: The degradable AmB-DDS can effectively suppress the inflammation of the rabbit model of Aspergillus fumigatus endophthalmitis. As an alternative to the current routine therapy, it can be used for the treatment of Aspergillus fumigatus endophthalmitis.

[Retrospective study of suppurative keratitis in 1054 patients].

OBJECTIVE: To analyze the etiological and clinical characteristics of 1054 cases with suppurative keratitis. METHODS: Medical records of 1054 inpatients with suppurative keratitis at the Qingdao Eye Hospital, Shandong Eye Institute from January 1999 to December 2004 were retrospectively reviewed for the analysis of demographic features, duration of symptoms, risk factors, previous therapy and laboratory findings. RESULTS: Fungal keratitis (61.9%) was the most common type in suppurative keratitis inpatients. Middle aged patients (between 41 - 50 years, 27.3%) and farm workers (82.9%) were the most common groups. Corneal trauma was noted as the most common risk factor. The positive rate of direct microscopic examination of potassium hydroxide (KOH) wet mounts was 88.7% for the diagnosis of fungal keratitis, but the positive rate of microscopic examination of Gram staining was only 43.4% in detecting bacterial keratitis. The most common type of fungi isolated was fusarium species (437 cases, 73.3%), followed by aspergillus species (72 cases, 12.1%). Pseudomonas aeruginosa was the most commonly isolated bacteria (35.7%), followed by staphylococcus epidermidis (22.5%). CONCLUSIONS: Fungal keratitis is the most common type in severe suppurative corneal ulcers and its incidence shows an increasing tendency progressively. As a rapid, simple and effective diagnostic method of fungal keratitis, the application of direct microscopic examination of KOH wet mounts should be used more extensively. A rapid and effective detecting technique of bacterial keratitis is required urgently.

[Spectrum of infection of fungal keratitis: analysis of 654 cases].

OBJECTIVE: To investigate the spectrum of infection and epidemiological features of fungal keratitis (FK). METHODS: The demographic data, risk factors, clinical features, laboratory findings, and treatment strategies of 654 patients with FK in Qingdao area, 396 males and 258 females, aged 44.9 +/- 12.5 (7 - 80), hospitalized January 1999 - September 2004 were collected and analyzed. RESULTS: FK patients accounted for 61.9% of the patients hospitalized for infectious keratitis. The ratio between the FK male and female patients was 1.5:1. The age distribution was as follows: 31.0% of the patients were aged 41 - 50, 26.5% of them were aged 31 - 40, 21.1% aged 51 - 60, 9.3% aged 61 - 70, etc. 89.9% of the FK patients were peasants. Corneal trauma was the most common risk factor (51.4%), especially injury by plant mater (25.7%). The incidence of FK was higher in the harvest seasons (autumn and winter) and showed a tendency to increase year by year. The positive rate of direct microscopic examination of potassium hydroxide (KOH) wet mounts was 88.7%. Most of the isolated fungi were Fusarium species (73.3%). followed by Aspergillus species (12.1%). Surgical intervention was performed on 604 eyes (92.4%), including therapeutic penetrating keratoplasty (66.0%, 399 cases) and therapeutic lamellar keratoplasty (29.3%, 177 cases). Global integrity was preserved in 626 cases (95.7%). CONCLUSION: Fusarium species are the most predominant pathogens of FK in Qingdao area. Rapid, simple, and high specific, direct microscopic examination of KOH wet mounts is worth spreading. Corneal transplantation remains the most effective approach to cure severe FK and is proposed to be performed at the early stage of FK.