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 Table of Contents  
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 57-59

Kocuria rhizophila dacryocystitis: Report of a rare causative organism in a common clinical condition

1 Department of Microbiology, Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Medical Research Foundation, Sankara Nethralya, Chennai, Tamil Nadu, India
2 Department of Microbiology, L & T Microbiology Research Centre, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission28-Jul-2021
Date of Acceptance26-Oct-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Bipasha Mukherjee
Orbit, Oculoplasty, Reconstructive and Aesthetic Services Medical Research Foundation 18, College Road, Chennai - 600 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_113_21

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A 3-year-old female child presented to us with complaints of watering in the left eye since birth, along with swelling near the medial canthus of the left eye for 1 week. External examination revealed a burst lacrimal sac abscess. The child underwent left eye probing with intubation. Cultures of the lacrimal sac contents revealed Kocuria rhizophila, a Gram-positive bacterium, as the primary pathogen. K. rhizophila was identified based on phenotypic characteristics and the VITEK-2 system. On follow-up visit, she had a recurrence of nasolacrimal duct obstruction with discharge from the left eye and subsequently underwent dacryocystorhinostomy. This study reports the first case K. rhizophila dacryocystitis, its clinicomicrobiological correlation, and management.

Keywords: Dacryocystitis, dacryocystorhinostomy, Kocuria rhizophila, probing

How to cite this article:
Sheerin A A, Anand A R, Mukherjee B. Kocuria rhizophila dacryocystitis: Report of a rare causative organism in a common clinical condition. TNOA J Ophthalmic Sci Res 2022;60:57-9

How to cite this URL:
Sheerin A A, Anand A R, Mukherjee B. Kocuria rhizophila dacryocystitis: Report of a rare causative organism in a common clinical condition. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Jun 29];60:57-9. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/57/340339

  Introduction Top

Dacryocystitis secondary to congenital nasolacrimal duct obstruction (CNLDO) is common among children, 95% of which resolve spontaneously by 1 year of age with only a few requiring surgical interventions.[1]

Here, we report the first case of dacryocystitis due to the Gram-positive bacterium, Kocuria rhizophila, and highlight the pathogenic potential of an organism that is normally a commensal of the skin and oral mucosa.

  Case Report Top

A 3-year-old child was brought by her parents with complaints of watering in the left eye since birth and redness and swelling near the medial canthus of the left eye for 1 week [Figure 1]a. Visual acuity by Lea symbols at 3 m was 6/9.5 in the right eye and 6/19 on the left eye. Finger tension, anterior and posterior segment examinations were normal in both the eyes. There was swelling near the left lacrimal sac area with a discharging sinus. Regurgitation on pressure over the lacrimal sac (ROPLAS) was negative in both the eyes. A diagnosis of left lacrimal sac abscess with draining fistula secondary to CNLDO was made, and left eye probing was advised under general anesthesia.
Figure 1: (a) Clinical picture of the child at presentation showing excoriated skin around the lacrimal sac with discharging sinus in the left eye. (b) Scarred surgical site with discharging sinus

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However, the child was lost to follow-up and came back after 3 months with persistent discharge from the left eye and subsequently underwent left eye probing. A membranous block was felt, which was opened up by applying gentle pressure, and a giveaway feeling was appreciated. The probe was visualized in the inferior meatus using a pediatric nasal endoscope. Serial dilatation was carried out with the increasing size of the probes. Syringing was found to be patent, and monocanalicular Crawford intubation was done through the upper canaliculus.

The sample obtained from the lacrimal sac contents was sent for routine microbiological investigations. Gram-stained smears of the sample revealed Gram-positive cocci. Cultures grew Gram-positive cocci, which was identified as Kocuria rhizophila by the VITEK-2 system using the ID-GP card (Biomerieux, France). The identification was categorized as excellent (correlation of >90% with database). The bacterium isolated was susceptible to gentamicin and intermediate susceptibility to ciprofloxacin.

The child was prescribed topical ciprofloxacin, oral cefixime, and steroid eye drops. The tube was left in situ. The child was asked to review after 1 week. On review, the raw area had healed. Her parents were instructed to start lacrimal sac massage and to review after 3 weeks.

On the follow-up visit, the child had a recurrence of symptoms, and a discharging sinus was noted [Figure 1]b. The child was started on gentamicin eye drops, and external dacryocystorhinostomy was performed subsequently.

On postoperative day 1, the child was comfortable. The child was discharged with topical ciprofloxacin ointment and steroid eye drops. During the last follow-up visit at 6 weeks, the child was asymptomatic, the wound was healthy, ROPLAS was negative, and tear film height was within normal limits and the child did not show any signs of recurrence.

  Discussion Top

Dacryocystitis is an infection of the lacrimal sac due to obstruction to the nasolacrimal duct which can be congenital or acquired secondary to trauma, respiratory, or conjunctival infection.[1] CNLDO is most commonly due to blockage at the valve of Hasner.[2] Dacryocystitis is characterized by epiphora, pain, expression of mucoid reflux on compression over the sac area, warmth, and erythema of the overlying skin. Untreated dacryocystitis can lead to permanent injury of the lacrimal passage, sight, and even life-threatening situations such as orbital cellulitis, abscess, meningitis, and cavernous sinus thrombosis.[1],[2]

There are limited studies available regarding the microbiological profile in children. A study by Ban et al. showed that, in pediatric dacryocystitis, Streptococcus pneumoniae and Staphylococcus aureus were the leading pathogen for acute and chronic dacryocystitis, respectively. Other organisms which have been encountered so far are Haemophilus influenzae, Candida, Pantoea, Proteus, Bacteroides, Sporothrix, and Ebstein Barr virus.[3] In the present case, we isolated a rare organism, K. rhizophila from the lacrimal sac contents.

K rhizophila is a Gram-positive coccus of the family Micrococcaceae in the phylum Actinobacteria and has been isolated from a variety of natural sources such as freshwater, soil, fermented foods, sludge, and fish gut forming complex biofilm along with a wide range of organisms. The organism is generally a commensal from the skin and mucous membranes.[4] It has a small genome size and is tolerant to a wide range of organic solvents and grows robustly in various conditions. More recently, attention has been drawn to clinical aspects of Kocuria. These have been found to cause infections such as endocarditis, pneumonia, and sepsis predominantly in immunocompromised patients and infections related to implanted foreign bodies such as IV lines and catheters.[5],[6] Kocuria requires advanced molecular techniques such as Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF-MS),16S rRNA gene-based sequencing, or automated identification systems such as VITEK for their identification.[7] Becker et al. found that these are generally sensitive to all beta-lactams, macrolides, glycopeptides, and quinolones except norfloxacin.[5]

The first line of treatment in acute dacryocystitis would be antimicrobial therapy. Antibiotics used empirically are penicillins, cephalosporins, clindamycin, and vancomycin. Surgery is mandatory when conservative treatment fails. Probing remains the first choice and is successful when performed early and combined with perioperative antibiotics and intubation. Intubation helps to maintain the patency of the newly created lacrimal drainage passage by preventing the formation of granulation-related obstruction.[8] The duration of stenting ranges from 3 weeks to 6 months, and it can be monocanalicular or bicanalicular with no difference in outcomes. With increasing age and associated complications, there is a risk of failure of these modalities.[8] This child had a recurrence of symptoms, and hence dacryocystorhinostomy was planned. Dacryocystorhinostomy poses challenges in children because of anatomical differences and the need for special instrumentations. It has a very good prognosis when it is done meticulously.[9],[10]

  Conclusion Top

Dacryocystitis in children generally resolves spontaneously or with antimicrobial therapy with only a few requiring surgeries. The culture and sensitivity of the discharge can guide us in selecting the appropriate antibiotics. Nonresolving infections should raise the suspicion of rare organisms such as Kocuria which are emerging as human pathogens and require advanced laboratory techniques for identification. Timely intervention with appropriate management and planning surgery at the earliest can prevent long-term and deadly complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Faden HS. Dacryocystitis in children. Clin Pediatr (Phila) 2006;45:567-9.  Back to cited text no. 1
Williams KJ, Allen RC. Paediatric orbital and periorbital infections. Curr Opin Ophthalmol 2019;30:349-55.  Back to cited text no. 2
Ali MJ. Pediatric acute dacryocystitis. Ophthalmic Plast Reconstr Surg 2015;31:341-7.  Back to cited text no. 3
Whon TW, Kim HS, Bae JW. Complete genome sequence of Kocuria rhizophila BT304, isolated from the small intestine of castrated beef cattle. Gut Pathog 2018;10:42.  Back to cited text no. 4
Becker K, Rutsch F, Uekötter A, Kipp F, König J, Marquardt T, et al. Kocuria rhizophila adds to the emerging spectrum of micrococcal species involved in human infections. J Clin Microbiol 2008;46:3537-9.  Back to cited text no. 5
Pierron A, Zayet S, Toko L, Royer PY, Garnier P, Gendrin V. Catheter-related bacteremia with endocarditis caused by Kocuria rhizophila. Infect Dis Now 2021;51:97-8.  Back to cited text no. 6
Boudewijns M, Vandeven J, Verhaegen J, Ben-Ami R, Carmeli Y. Vitek 2 automated identification system and Kocuria kristinae. J Clin Microbiol 2005;43:5832.  Back to cited text no. 7
Tai EL, Kueh YC, Abdullah B. The use of stents in children with nasolacrimal duct obstruction requiring surgical intervention: A systematic review. Int J Environ Res Public Health 2020;17:E1067.  Back to cited text no. 8
Sen P, Jain E, Mohan A, Kumar A. Surgical outcome of external dacryocystorhinostomy with silicone intubation for recurrent lacrimal abscess in children younger than 6 years. J Pediatr Ophthalmol Strabismus 2019;56:188-93.  Back to cited text no. 9
Nemet AY, Fung A, Martin PA, Benger R, Kourt G, Danks JJ, et al. Lacrimal drainage obstruction and dacryocystorhinostomy in children. Eye (Lond) 2008;22:918-24.  Back to cited text no. 10


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