복합감염으로 오인되어 치료 실패한 다제내성 아시네토박터 바우마니 각막염 1예
Failed Treatment of Multidrug-resistant Acinetobacter Baumannii Keratitis Mistaken for a Mixed Infection
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목적: 장기간 콘택트렌즈를 착용한 환자에서 발생한 다제내성 아시네토박터 바우마니 각막염 증례를 보고하고자 한다. 증례요약: 20여년간 주간착용 소프트렌즈를 사용한 48세 남자가 시력저하와 안통으로 전원되었다. 세극등현미경상 큰 각막상피결손, 원형 기질침윤을 보였으나 전방축농은 없었다. 목시플록사신, polyhexamethylene biguanide 점안, 경구 항생제로 치료를 시작하였다. 각막침윤이 심해져 재시행한 각막찰과에서 그람양성균, 수산화칼륨도말 균사 양성, 바실러스균이 배양되었다. 입원하여 반코마이신, 보리코나졸, 암포테리신B를 추가하고 경구 항진균제를 사용하였다. 각막상피결손이 회복되다가 증가하고 각막내피반도 생기는등 악화되어 전방 내 보리코나졸, 암포테리신B를 주사하였다. 네 차례 배양검사에서 모두 음성이었다. 전체결막판피복술을 하였으나통증이 심해져 결국 안구내용제거술을 받았다. 안구내용물 배양에서 미노사이클린을 제외한 모든 약제에 내성을 보이는 아시네토박터 바우마니가 검출되었다. 결론: 장기간 콘택트렌즈를 착용한 환자에서 가시아메바, 진균의 복합감염뿐만 아니라 그람음성균을 먼저 고려해야 하고 다제내성아시네토박터 바우마니도 염두에 둬야 한다.
Abstract
Purpose: To report treatment failure of multidrug-resistant Acinetobacter baumannii keratitis in a patient wearing contact lenses for a long time. Case summary: A 48-year-old man using daytime soft lenses for 20 years was transferred due to decreased visual acuity and eye pain. Slit-lamp biomicroscopy showed a large corneal epithelial defect and stromal infiltration, but no hypopyon. Treatment was initiated with moxifloxacin, polyhexamethylene biguanide eye drops, and oral antibiotics. Corneal infiltration worsened, corneal scrapings and culture were performed. Gram staining showed Gram-positive bacteria, potassium hydroxide (KOH) hyphae- positive, and culture yielded Bacillus. He was hospitalized and vancomycin, voriconazole, and amphotericin B eye drops were administered. Oral antifungal agents were also prescribed. The corneal epithelial defect was restored from temporal side for a while, and then deteriorated with an endothelial plaque. Therefore, voriconazole and amphotericin B were injected intracamerally. All four repeated culture tests were negative. Despite total conjunctival flap, the patient complained of severe pain and eventually underwent evisceration. In the culture of intraocular contents, Acinetobacter baumannii, which is resistant to all drugs except minocycline, was detected. Conclusions: In patients wearing contact lens for a long time, not only mixed infection with acanthamoeba and fungi, but also gram-negative bacteria should be considered first, and multidrug-resistant Acinetobacter baumannii should also be considered.
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