Atypical fulminant corneal ulcer caused by Streptococcus mitis

To report a case of atypical corneal ulcer caused by Streptococcus mitis. A 65-year-old man presented to the cornea services with diminution of vision, pain, redness, and watering in the right eye for 10 days. His visual acuity was hand motion close to face (HMCF) in the right eye and 20/20 in the left eye. Medical history revealed that he had been on oral and topical antiviral medication since 7 days. On slit-lamp examination, he had diffuse conjunctival congestion with inferior mid-stromal whitish-yellow infiltrates 5 × 5 mm with overlying epithelial defect of 4.5 × 4.5 mm. His corneal scrapings were sent for microbiological evaluation. There was no history of any systemic illness. He was started empirically on antifungal treatment in the form of natamycin 5% hourly, along with topical moxifloxacin 0.5%, based on clinical judgment. Gram stain report came out to be negative, but bacterial culture after overnight incubation revealed Streptococcus mitis using MALDI-TOF-MS (Vitek MS, bioMérieux). The management was modified to topical fortified vancomycin 1%, amikacin 2.5%, linezolid 0.2% drops, and oral linezolid 600 mg twice a day based on the sensitivity pattern. In view of progressive worsening on medical management, therapeutic keratoplasty was performed, followed by optical keratoplasty after 6 months. Optical keratoplasty was performed for visual rehabilitation after 6 months of therapeutic keratoplasty with a final visual acuity of 6/60. Timely surgical intervention, along with precise medical management guided by culture sensitivity pattern, leads to optimal visual and anatomical outcomes.