Crystalline lens dislocation as a presenting sign of Streptococcus pyogenes invasive infections
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Introduction To describe two cases of crystalline lens dislocation as a presenting feature of invasive group A Streptococcus (GAS) infection and its management. Case presentation We report on a 58-year-old female and a 36-year-old male who presented in 2024 with acute vision loss and severe ocular and systemic symptoms. Both patients were found to have lens dislocation and were diagnosed with invasive GAS infection. The 58-year-old female had a complicated clinical course leading to enucleation, while the 36-year-old male responded favorably to early and aggressive treatment with systemic and intravitreal antibiotics. The responsible GAS strains were sequence type (ST) 28 and ST433, respectively. Conclusion These cases highlight the importance of recognizing crystalline lens dislocation as a potential sign of ocular GAS infection. Two specific strain types of GAS associated with these findings, ST28 and ST433, are reported. In patients with GAS sepsis presenting with corneal edema and zonular loss, clinicians should immediately initiate treatment, including intravitreal antibiotic injections and systemic therapy. Prompt and aggressive management can be crucial in preserving ocular structures.
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Comments to Author
Please ONLY put comments for the Author(s) in here 1. Give some pictures and flowcharts
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
No: Yes ethical principles have been looked after
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I am recommending a major revision based on the reviewers' feedback, which highlights the need for additional microbiological and clinical details, including susceptibility testing, whole genome sequencing findings and inflammatory markers. Clarifications are required regarding the treatment timeline, antimicrobial regimens and systemic involvement. Structural enhancements, such as a pictorial timeline, additional images and flowcharts, are also suggested to improve clarity and presentation. These substantial revisions are necessary to strengthen the manuscript’s scientific and clinical value.
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Comments to Author
The authors are to be commended on a well-written case report characterising two unusual cases of iGAS infection which is interesting to read and a useful addition to the literature. It is well structured and has a logical flow. Also some excellent photographs are included. Overall, I think it could benefit from a little more in-depth microbiology/general clinical detail being included. The case report may also benefit from a pictorial timeline including antimicrobial therapy (systemic and intravitreal) and surgical intervention to make the timeline for both cases clearer to the reader. Minor comments Line 32- would be more accurate to add and "with systemic symptoms" as was not just the ocular symptoms for case 2 Line 33- which year did the cases occur in? Line 54- Might be useful to add a line about …
Comments to Author
The authors are to be commended on a well-written case report characterising two unusual cases of iGAS infection which is interesting to read and a useful addition to the literature. It is well structured and has a logical flow. Also some excellent photographs are included. Overall, I think it could benefit from a little more in-depth microbiology/general clinical detail being included. The case report may also benefit from a pictorial timeline including antimicrobial therapy (systemic and intravitreal) and surgical intervention to make the timeline for both cases clearer to the reader. Minor comments Line 32- would be more accurate to add and "with systemic symptoms" as was not just the ocular symptoms for case 2 Line 33- which year did the cases occur in? Line 54- Might be useful to add a line about the normal spectrum of GAS disease involving the eye. Line 58- would be helpful to add a line about the US context/epidemiology of iGAS there. Is iGAS notifiable in the US? Could mention UK M1 UK lineage Could mention iGAS epidemiology in US since COVID. Line 65- could use left eye and right eye as not an ophthalmology journal. Line 69- could add "laser" to clarify what YAG peripheral iridotomy is as not an ophthalmology journal. Line 79- there would be merit in adding some parameters such as WCC, neutrophil count and CRP. Other findings e.g. deranged renal function or LFTs. Line 82- please include statement about susceptibility testing and results. Line 88- are there any other WGS findings such as virulence genes, AMR genes? Have you uploaded your sequences to GenBank? Please add accession numbers. You could add more details about the sequencing rather than referring to ref 6. Line 94- where in the tropics? Was the contact a child? Did the contact's impetigo lesions get swabbed? Line 97- there would be merit in adding some parameters such as WCC, neutrophil count and CRP. Other findings e.g. deranged renal function or LFTs. Line 101- did the broad-spectrum antibiotics get rationalised at some point? Line 103- was this the only MRI finding? Line 112- as in systemic clindamycin or intravitreal? Please clarify as, so far the patient doesn't appear to be on systemic clindamycin. Please include statement about all susceptibility testing results. Line 113- is there a reason why this patient received IVIG but the other one didn't? Line 122/123- did you consider doing 16s? ?is "pathology" histopathology? was the aspirate sent to the micro lab Gram stain negative? Line 163- please add a ref for certain emm types linked to specific presentations General Please add doses and length of treatment that both cases received. Did either of the cases get admitted to ICU? I look forward to seeing a revised version.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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