Nocardia sienata: a new causative species of infectious keratitis.

A 25-year-old man presented with a 2-month history of progressively worsening left eye pain and an atypical corneal ring infiltrate. His condition deteriorated despite topical antibiotic therapy. Cultures for bacteria, fungus and acanthamoeba, repeated twice, all demonstrated no growth. On third corneal scraping, culture on Middlebrook agar grew colonies after 3 weeks of incubation. Sixteen-second deep sequencing identified Nocardia sienata as the pathogen. This species of Nocardia has not previously been described as a causative pathogen for infectious keratitis. Sloughing and loose epithelium with recurrent filament formation are unusual in infectious keratitis and could be associated with this species. In culture-negative cases, clinicians should consider Nocardia as a cause of keratitis despite its rarity outside of south Asia and use steroids cautiously. Next generation sequencing technology may facilitate identification of the causate of keratitis and can be especially useful in culture-negative cases and with unexpected pathogens.

Rise and regional disparities in buprenorphine utilization in the United States.

PURPOSE: Buprenorphine is an opioid partial agonist used to treat opioid use disorder. While several policy changes have attempted to increase buprenorphine availability, access remains well below optimal levels. This study characterized how buprenorphine utilization in the United States has changed over time and whether there are regional disparities in distribution of the medication. METHODS: The amount of buprenorphine distributed from 2007 to 2017 was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Ordering System. Data were expressed as the percent change and milligrams per person in each state. The formulations and cost for prescriptions covered by Medicaid (2008 to 2018) were also examined. RESULTS: Buprenorphine distributed to pharmacies increased about 7-fold (476.8 to 3179.9 kg) while the quantities distributed to hospitals grew 5-fold (18.6 to 97.6 kg) nationally from 2007 to 2017. Buprenorphine distribution per person was almost 20-fold higher in Vermont (40.4 mg/person) relative to South Dakota (2.1 mg/person). There was a strong association between the number of physicians authorized to prescribe buprenorphine and distribution per state (r[49] = +0.94, P < .0005). The buprenorphine/naloxone sublingual film (Suboxone) was the predominant formulation (92.6% of 0.31 million Medicaid prescriptions) in 2008 but accounted for less than three-fifth (57.3% of 6.56 million prescriptions) in 2018. CONCLUSIONS: Although buprenorphine availability has substantially increased over the last decade, distribution was very nonhomogeneous across the United States.

Peripheral ulcerative keratitis associated with vasculitis manifesting asymmetrically as fuchs superficial marginal keratitis and terrien marginal degeneration.

PURPOSE: To report a case of bilateral peripheral corneal thinning with an appearance of Fuchs superficial marginal keratitis in the right eye and Terrien marginal degeneration in the left eye. METHODS: Interventional case report. RESULTS: A 28-year-old woman presented with bilateral corneal thinning and a pseudopterygium in the right eye and peripheral corneal thinning in the left eye. Laboratory examinations were negative. Over the next several years, the patient experienced periodic episodes of bilateral ocular redness and discomfort associated with gradual corneal thinning. However, other signs of progression were different in each eye. Pseudopterygium growth was observed in the right eye, consistent with Fuchs superficial marginal keratitis. Progressive lipid deposition at the leading edge of corneal thinning was observed in the left eye, consistent with Terrien marginal degeneration. Chronic topical corticosteroid therapy was initiated with little, if any, subsequent disease progression. A perinuclear antineutrophil cytoplasmic antibody (p-ANCA)-positive vasculitis was subsequently diagnosed. CONCLUSIONS: Fuchs superficial marginal keratitis and Terrien marginal degeneration may represent different clinical features of the same disease process. Laboratory investigation for underlying systemic disease may be warranted in patients with the appearance of either disorder. Chronic antiinflammatory therapy may be effective in limiting the progression of corneal thinning in these diseases.