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Bacillus cereus panophthalmitis associated with injection drug use
International Journal of Infectious Diseases 26 (2014) e165–e166
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Case Report
Bacillus cereus panophthalmitis associated with injection drug use Nilay Kumar a,*, Neetika Garg b, Nilesh Kumar c, Nicholas Van Wagoner d a
Department of Medicine, Cambridge Health Alliance, Harvard Medical School, 1493 Cambridge St, Cambridge, MA 02139, USA Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA c Department of Medicine, Manipal University, Manipal, Karnataka, India d Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA b
A R T I C L E I N F O
Article history: Received 23 October 2013 Received in revised form 18 January 2014 Accepted 20 January 2014 Corresponding Editor: Eskild Petersen, Aarhus, Denmark
S U M M A R Y
We report a case of rapidly progressive vision loss in a young woman with a history of injection drug use. Subsequent enucleation of the affected eye was done and Bacillus cereus grew on tissue culture. B. cereus is a rare cause of endogenous endophthalmitis due to hematogenous seeding of the vitreous in the setting of injection drug use. ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/3.0/).
Keywords: Bacillus cereus Endophthalmitis Injection drug use Panophthalmitis
1. Introduction Bacillus cereus eye infections are frequently associated with traumatic eye injuries and post-operative complications. Rarely, endogenous B. cereus endophthalmitis may develop as a result of hematogenous seeding due to intravenous drug use. In this paper, we describe the case of a young woman with fulminant B. cereus endophthalmitis/panophthalmitis in association with intravenous methamphetamine use. Despite early and aggressive treatment with broad-spectrum intravenous antibiotics she progressed to complete vision loss necessitating enucleation to prevent intracranial spread of infection. B. cereus endopthalmitis should be considered in the differential diagnosis when evaluating intravenous drug users with visual symptoms. 2. Case report An 18-year-old Caucasian woman with a history of intravenous drug abuse presented with a severe left-sided frontal headache followed by left-sided peri-orbital pain, redness, and swelling for 1 week. Symptoms began as a mild headache, which progressed to swelling and redness of the left eye, decreased visual acuity, and
* Corresponding author. E-mail address: [email protected] (N. Kumar).
severe pain on eye movement within 2–3 days. Evaluation at another facility 2 days prior to presentation was suggestive of endophthalmitis, and treatment with intravenous vancomycin and piperacillin–tazobactam was initiated. In the following 48 h her symptoms progressed relentlessly to complete vision loss in the left eye, prompting transfer to our tertiary medical center. She smoked marijuana and used methamphetamines, occasionally sharing needles for injection drug use. The most recent episode of injection drug use was 1 week prior to admission. On examination, there was left eye proptosis with peri-orbital swelling, erythema, and exquisite tenderness to palpation. There was no light perception in the affected eye. Marked sinus tenderness was noted. Routine laboratory tests showed a white blood cell count of 18 109/l with 86% neutrophils; serology for HIV 1 and 2 was negative. A tomography scan of the orbits showed proptosis and enlargement of the left globe, with circumferential scleral enhancement (Figures 1 and 2). There was no evidence of cavernous sinus thrombosis. Initial differential diagnoses included polymicrobial aerobic/anaerobic infection, staphylococcal/streptococcal infection, mucormycosis, and invasive aspergillosis. Intravenous vancomycin and piperacillin–tazobactam were continued. An emergent ophthalmology consult was obtained. Given the progressive nature of the infection despite antibiotics and the potential for intracranial spread of the infection, an urgent enucleation with peri-orbital tissue debridement was performed. Gram stain of the ocular tissue showed abundant Gram-positive
http://dx.doi.org/10.1016/j.ijid.2014.01.019 1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
e166
N. Kumar et al. / International Journal of Infectious Diseases 26 (2014) e165–e166
Figure 1. Coronal reconstructed contrast-enhanced computed tomography image showing significant enlargement of the left globe along with diffuse contrast enhancement of the sclera suggestive of panophthalmitis.
rods and tissue culture grew Bacillus cereus. She completed 12 days of treatment with intravenous vancomycin and was discharged on oral ciprofloxacin to complete 6 weeks of antibiotic treatment. She was doing well at follow-up 3 months after discharge. 3. Discussion Infectious complications are common among injection drug users (IDUs). Staphylococcus aureus, Streptococcus, and Gramnegative rods are commonly implicated in such infections. An increasing number of reports have described Bacillus species as pathogens in IDUs. B. cereus is a ubiquitous, motile, endospore-forming, Grampositive rod. It is perhaps best known as a cause of food poisoning associated with the consumption of stale fried rice and is often regarded to be a ‘non-pathogenic’ contaminant when isolated in other settings. Rare cases of B. cereus meningitis, endocarditis, and septicemia have been reported in high-risk patients with acute leukemia and other immunodeficiency states.1 Exogenous endophthalmitis due to B. cereus is relatively common in the setting of traumatic globe injuries,1 however reports of endogenous endophthalmitis due to B. cereus in association with injection drug use are rare.2–4 These infections are extremely fulminant with rapid progression to panophthalmitis and loss of light perception within hours of intraocular inoculation. The pathogenesis of ocular infections in IDUs involves transient bacteremia and lodging of infectious emboli in the retinal and ciliary arterioles. B. cereus is a highly virulent organism due to the production of enzymes lecithin, hemolysins, and phospholipase C, resulting in rapid tissue destruction.1 Expedited treatment with intravenous
Figure 2. Horizontal contrast-enhanced computed tomography image showing significant enlargement of the left globe along with diffuse contrast enhancement of the sclera suggestive of panophthalmitis.
vancomycin, aminoglycosides, or fluoroquinolones is the treatment of choice.1–4 Systemic antibiotics are indicated in all cases of endogenous endophthalmitis due to B. cereus. In cases of exogenous B. cereus endophthalmitis, as in the case of traumatic globe injuries, intravitreal antibiotics including vancomycin and ceftazidime are indicated with or without vitrectomy.5 Despite adequate treatment, outcomes are typically poor, resulting in complete vision loss, phthisis bulbi, or enucleation. There were 35 cases of B. cereus eye infection reported in the 20th century, of which 70% resulted in vision loss due to enucleation.1 In conclusion, we have described a case of fulminant B. cereus panophthalmitis with irreversible vision loss associated with injection drug use. Internists and infectious disease specialists should remain cognizant of ocular B. cereus infections when evaluating IDUs with retro-orbital headaches, eye pain, or decreased visual acuity. Conflict of interest: The authors have no conflicts of interest to report.
References 1. Drobniewski FA. Bacillus cereus and related species. Clin Microbiol Rev 1993;6:324–38. 2. Hatem G, Merritt JC, Cowan CL. Bacillus cereus panophthalmitis after intravenous heroin. Ann Ophthalmol 1979;11:431–40. 3. Shamsuddin D, Tuazon CU, Levy C, Curtin J. Bacillus cereus panophthalmitis: source of the organism. Rev Infect Dis 1982;4:97–103. 4. Young EJ, Wallace RJ, Ericsson CD, Harris RA, Clarridge J. Panophthalmitis due to Bacillus cereus. Arch Intern Med 1980;140:559–60. 5. Durand ML. Endophthalmitis. Clin Microbiol Infect 2013;19:227–34.
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Case Report
Bacillus cereus panophthalmitis associated with injection drug use Nilay Kumar a,*, Neetika Garg b, Nilesh Kumar c, Nicholas Van Wagoner d a
Department of Medicine, Cambridge Health Alliance, Harvard Medical School, 1493 Cambridge St, Cambridge, MA 02139, USA Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA c Department of Medicine, Manipal University, Manipal, Karnataka, India d Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA b
A R T I C L E I N F O
Article history: Received 23 October 2013 Received in revised form 18 January 2014 Accepted 20 January 2014 Corresponding Editor: Eskild Petersen, Aarhus, Denmark
S U M M A R Y
We report a case of rapidly progressive vision loss in a young woman with a history of injection drug use. Subsequent enucleation of the affected eye was done and Bacillus cereus grew on tissue culture. B. cereus is a rare cause of endogenous endophthalmitis due to hematogenous seeding of the vitreous in the setting of injection drug use. ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/3.0/).
Keywords: Bacillus cereus Endophthalmitis Injection drug use Panophthalmitis
1. Introduction Bacillus cereus eye infections are frequently associated with traumatic eye injuries and post-operative complications. Rarely, endogenous B. cereus endophthalmitis may develop as a result of hematogenous seeding due to intravenous drug use. In this paper, we describe the case of a young woman with fulminant B. cereus endophthalmitis/panophthalmitis in association with intravenous methamphetamine use. Despite early and aggressive treatment with broad-spectrum intravenous antibiotics she progressed to complete vision loss necessitating enucleation to prevent intracranial spread of infection. B. cereus endopthalmitis should be considered in the differential diagnosis when evaluating intravenous drug users with visual symptoms. 2. Case report An 18-year-old Caucasian woman with a history of intravenous drug abuse presented with a severe left-sided frontal headache followed by left-sided peri-orbital pain, redness, and swelling for 1 week. Symptoms began as a mild headache, which progressed to swelling and redness of the left eye, decreased visual acuity, and
* Corresponding author. E-mail address: [email protected] (N. Kumar).
severe pain on eye movement within 2–3 days. Evaluation at another facility 2 days prior to presentation was suggestive of endophthalmitis, and treatment with intravenous vancomycin and piperacillin–tazobactam was initiated. In the following 48 h her symptoms progressed relentlessly to complete vision loss in the left eye, prompting transfer to our tertiary medical center. She smoked marijuana and used methamphetamines, occasionally sharing needles for injection drug use. The most recent episode of injection drug use was 1 week prior to admission. On examination, there was left eye proptosis with peri-orbital swelling, erythema, and exquisite tenderness to palpation. There was no light perception in the affected eye. Marked sinus tenderness was noted. Routine laboratory tests showed a white blood cell count of 18 109/l with 86% neutrophils; serology for HIV 1 and 2 was negative. A tomography scan of the orbits showed proptosis and enlargement of the left globe, with circumferential scleral enhancement (Figures 1 and 2). There was no evidence of cavernous sinus thrombosis. Initial differential diagnoses included polymicrobial aerobic/anaerobic infection, staphylococcal/streptococcal infection, mucormycosis, and invasive aspergillosis. Intravenous vancomycin and piperacillin–tazobactam were continued. An emergent ophthalmology consult was obtained. Given the progressive nature of the infection despite antibiotics and the potential for intracranial spread of the infection, an urgent enucleation with peri-orbital tissue debridement was performed. Gram stain of the ocular tissue showed abundant Gram-positive
http://dx.doi.org/10.1016/j.ijid.2014.01.019 1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
e166
N. Kumar et al. / International Journal of Infectious Diseases 26 (2014) e165–e166
Figure 1. Coronal reconstructed contrast-enhanced computed tomography image showing significant enlargement of the left globe along with diffuse contrast enhancement of the sclera suggestive of panophthalmitis.
rods and tissue culture grew Bacillus cereus. She completed 12 days of treatment with intravenous vancomycin and was discharged on oral ciprofloxacin to complete 6 weeks of antibiotic treatment. She was doing well at follow-up 3 months after discharge. 3. Discussion Infectious complications are common among injection drug users (IDUs). Staphylococcus aureus, Streptococcus, and Gramnegative rods are commonly implicated in such infections. An increasing number of reports have described Bacillus species as pathogens in IDUs. B. cereus is a ubiquitous, motile, endospore-forming, Grampositive rod. It is perhaps best known as a cause of food poisoning associated with the consumption of stale fried rice and is often regarded to be a ‘non-pathogenic’ contaminant when isolated in other settings. Rare cases of B. cereus meningitis, endocarditis, and septicemia have been reported in high-risk patients with acute leukemia and other immunodeficiency states.1 Exogenous endophthalmitis due to B. cereus is relatively common in the setting of traumatic globe injuries,1 however reports of endogenous endophthalmitis due to B. cereus in association with injection drug use are rare.2–4 These infections are extremely fulminant with rapid progression to panophthalmitis and loss of light perception within hours of intraocular inoculation. The pathogenesis of ocular infections in IDUs involves transient bacteremia and lodging of infectious emboli in the retinal and ciliary arterioles. B. cereus is a highly virulent organism due to the production of enzymes lecithin, hemolysins, and phospholipase C, resulting in rapid tissue destruction.1 Expedited treatment with intravenous
Figure 2. Horizontal contrast-enhanced computed tomography image showing significant enlargement of the left globe along with diffuse contrast enhancement of the sclera suggestive of panophthalmitis.
vancomycin, aminoglycosides, or fluoroquinolones is the treatment of choice.1–4 Systemic antibiotics are indicated in all cases of endogenous endophthalmitis due to B. cereus. In cases of exogenous B. cereus endophthalmitis, as in the case of traumatic globe injuries, intravitreal antibiotics including vancomycin and ceftazidime are indicated with or without vitrectomy.5 Despite adequate treatment, outcomes are typically poor, resulting in complete vision loss, phthisis bulbi, or enucleation. There were 35 cases of B. cereus eye infection reported in the 20th century, of which 70% resulted in vision loss due to enucleation.1 In conclusion, we have described a case of fulminant B. cereus panophthalmitis with irreversible vision loss associated with injection drug use. Internists and infectious disease specialists should remain cognizant of ocular B. cereus infections when evaluating IDUs with retro-orbital headaches, eye pain, or decreased visual acuity. Conflict of interest: The authors have no conflicts of interest to report.
References 1. Drobniewski FA. Bacillus cereus and related species. Clin Microbiol Rev 1993;6:324–38. 2. Hatem G, Merritt JC, Cowan CL. Bacillus cereus panophthalmitis after intravenous heroin. Ann Ophthalmol 1979;11:431–40. 3. Shamsuddin D, Tuazon CU, Levy C, Curtin J. Bacillus cereus panophthalmitis: source of the organism. Rev Infect Dis 1982;4:97–103. 4. Young EJ, Wallace RJ, Ericsson CD, Harris RA, Clarridge J. Panophthalmitis due to Bacillus cereus. Arch Intern Med 1980;140:559–60. 5. Durand ML. Endophthalmitis. Clin Microbiol Infect 2013;19:227–34.