- Email: [email protected]
Case of endogenous endophthalmitis caused by Klebsiella pneumoniae with magA and rmpA genes in an immunocompetent patient
J Infect Chemother (2013) 19:326–329 DOI 10.1007/s10156-012-0468-6
CASE REPORT
Case of endogenous endophthalmitis caused by Klebsiella pneumoniae with magA and rmpA genes in an immunocompetent patient Akira Sawada • Shinya Komori • Kazunari Udo Shinsuke Suemori • Kiyofumi Mochizuki • Mitsuru Yasuda • Kiyofumi Ohkusu
•
Received: 24 May 2012 / Accepted: 10 August 2012 / Published online: 20 September 2012 Ó Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2012
Abstract We report a case of endogenous endophthalmitis caused by Klebsiella pneumoniae in an immunocompetent patient. A 73-year-old man with acute epididymitis who had no history of diabetes mellitus developed endogenous endophthalmitis. The patient underwent anterior vitrectomy and intracapsular cataract extraction with intravitreal injections of both vancomycin and ceftazidime. After the surgery, he was treated with topical and intravenous antibiotics; however, the left eye perforated and was enucleated. Culture from vitreous biopsy specimens grew as K. pneumoniae, which was positive for both magA and rmpA. K. pneumoniae should be considered as a pathogen that can cause severe endogenous endophthalmitis in patients with urinary tract infection. The severity of the disease may be related to the virulence genes. Keywords Endogenous endophthalmitis Klebsiella pneumoniae Acute epididymitis magA rmpA
A. Sawada (&) S. Komori K. Udo S. Suemori K. Mochizuki Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan e-mail: [email protected] M. Yasuda Department of Urology, Gifu University Graduate School of Medicine, Gifu, Japan K. Ohkusu Department of Microbiology, Gifu University Graduate School of Medicine, Gifu, Japan
123
Introduction Endogenous bacterial endophthalmitis results from a blood-borne spread of bacteria with entrance into the intraocular space. It is associated with underlying medical conditions such as diabetes, gastrointestinal disorders, renal failure, heart disease, and malignancies in up to 90 % of the patients [1, 2]. Diabetes is a significant risk factor for the development of endogenous endophthalmitis and poor visual outcome [3]. However, a case series of cultureproven endogenous endophthalmitis has been reported in apparently healthy and immunocompetent individuals [4]. Earlier studies have reported that the most common bacterial organism causing endogenous bacterial endophthalmitis was Staphylococcus aureus [1]. In East Asia, it is more commonly (in 37–70 % of infections) caused by gram-negative organisms, particularly Klebsiella spp. [5]. Among the gram-negative organisms, Klebsiella pneumoniae is known to be the species most frequently responsible for endogenous bacterial endophthalmitis, especially in East Asian countries [2, 5]; e.g., K. pneumoniae was found in 48.4 % of infections [2]. Despite early diagnosis and treatment, the visual prognosis remains poor [1, 2, 5]. Lee et al. [2] reported that K. pneumoniae-associated endogenous endophthalmitis had significantly poorer visual outcomes than those with gram-positive cocci-associated endophthalmitis. Fung et al. [6] reported that K. pneumoniae serotype K1 was significantly associated with liver abscesses with the complication of endophthalmitis. Infections by the K. pneumoniae K1 and K2 capsular serotypes, the mucoid phenotypes, followed by their aerobactin production, were important determinants of virulence [7]. In addition, a close relationship of the mucoviscosity-associated (magA) gene and/or regulator of mucoid phenotype (rmpA) gene to the
J Infect Chemother (2013) 19:326–329
327
K. pneumoniae hypermucoviscosity phenotype has been pointed out [8]. We present here a case of endogenous K. pneumoniae endophthalmitis with acute epididymitis in an immunocompetent patient; both the magA and rmpA genes were identified in vitreous specimens.
Case report A 73-year-old nondiabetic man who had a history of lumbar spinal canal stenosis underwent prostate surgery at another hospital. After the surgery, he was treated with cefdinir (300 mg/day) and loxoprofen, a nonsteroidal antiinflammatory drug. Ten days later, he was examined at an eye clinic because of a 4-day history of blurred vision in the left eye and nausea. His visual acuity was light perception in the left eye and 20/20 in the right eye. The intraocular pressure was 14 mmHg in the right eye and 40 mmHg in the left eye. He was diagnosed with uveitis with secondary glaucoma and was referred to us for further therapy on the same day. Slit-lamp examination showed severe ciliary injection, corneal edema, and severe inflammation with a hypopyon in the anterior chamber of his left eye (Fig. 1). His left fundus could not be examined in detail because of hazy media. Ultrasonography of the posterior segment showed moderately dense infiltrations in the vitreous cavity, and the electroretinogram was completely extinguished in his left eye. His right eye was normal. With a tentative diagnosis of suspected endogenous endophthalmitis, he underwent emergency anterior vitrectomy and intracapsular cataract extraction with intravitreal injections of vancomycin (1 mg/eye) and ceftazidime (2 mg/eye). He was also treated with topical 0.5 % levofloxacin and 0.5 % cefmenoxime, 0.3 % ofloxacin ointment, and intravenous cefpirome (2 g/day). The vitreous aspirate showed a few gram-negative rods. On the following day, we began to determine the primary extraocular origin of the infection because there was no history of ocular trauma and ocular surgery. Physical examination showed a body temperature of 37.2 °C with testicular tenderness. Scrotal magnetic resonance imaging revealed bilateral testicular enlargement and the presence of a moderate hydrocele. No abnormalities were detected by chest roentgenography and computed tomography of the brain, chest, and liver. Laboratory tests demonstrated an elevated leukocyte count of 19,320/ll with 90 % of polymorphonuclear cells, a C-reactive protein level of 16.15 mg/dl, alkaline phosphatase level of 923 IU/l, c-glutamyl-transpeptidase level of 302 IU/l, creatinine level of 1.38 mg/dl, and blood urea nitrogen level of 32.4 mg/ml. The level of hemoglobin A1C was 5.6 %. Urinalysis
Fig. 1 External slit-lamp photograph of the left eye. The conjunctiva is erythematous and chemotic, and the cornea was thickened with inflammatory debris on its endothelium. The anterior chamber is severely irritated with a hypopyon
revealed a pH of 5.5, 1 ? protein, 1 ? white blood cell, 3 ? red blood cells, and 1 ? gram-negative bacilli. These findings led to a diagnosis of acute epididymitis. Two days after admission, the cefpirome was discontinued and replaced by imipenem (1 g/day) for 2 weeks. His ocular inflammation worsened, and the corneal wound ruptured 3 days after the first surgery. With the consent of the patient, his left eye was enucleated 2 days later. The same topical antibiotics were continued after the enucleation. The imipenem was switched to oral levofloxacin 500 mg daily for 7 days. Thereafter, the acute epididymitis gradually improved. Subsequently, cultures from vitreous biopsy specimens obtained during both vitrectomy and enucleation grew K. pneumoniae, which was positive for both the magA and rmpA genes. Polymerase chain reaction (PCR) was performed to amplify the magA and the rmpA genes, as previously described [2]. K. pneumoniae was found to be susceptible to piperacillin, ceftazidime, aztreonam, ceftriaxone, imipenem/cilastatin, amikacin, gentamicin, minocycline, levofloxacin, and vancomycin, and was resistant to sulbactam sodium/ampicillin sodium, and ampicillin (Table 1). Both blood and urine cultures on admission to our hospital were negative.
Discussion Immunocompromised states such as diabetes mellitus, renal failure, and malignancy are associated with a reduced host defense and are risk factors for the development of endogenous endophthalmitis [1, 2, 9, 10]. It has been reported that K. pneumoniae is a common cause of
123
328
J Infect Chemother (2013) 19:326–329
Table 1 Susceptibility testing results of Klebsiella pneumoniae Antimicrobial agent
Minimum inhibitory concentration (lg/ml)
Ampicillin
[16
Piperacillin
B16
Ceftazidime Cefazolin
B1 B8
Cefmetazole
B16
Cefdinir
B1
Imipenem/cilastatin
B1
Aztreonam
B1
Sulbactam/ampicillin
[16
Ceftriaxone
B1
Amikacin
B8
Gentamicin
B2
Cefozopran
B1
Minocycline
B2
Fosfomycin
128
Levofloxacin
B2
Sulfamethoxazole–trimethoprim
B1
Cefpodoxime proxetil
B1
endogenous bacterial endophthalmitis [2]. However, endogenous endophthalmitis caused by K. pneumoniae in immunocompetent patients in Japan is rare, with only three cases reported [11–13]. The mean age of the patients in these reports was 60 years, with a range of 52–71 years. All the cases were men; the primary source of the infection was liver abscess in two cases [12, 13] and septic pulmonary embolism in one case [11]. The visual outcomes in all these cases were poor. Our case was an older man without diabetes mellitus and malignancy, and the outcome was poor. We suggest that delayed diagnosis also leads to poor prognosis [5]. The primary sources of the endogenous K. pneumoniae endophthalmitis were from the hepatobiliary system (77.5 %), followed by the urinary tract (9.9 %), and respiratory system (4.2 %) [14]. Acute epididymitis is characterized by testicular pain and tender swelling of the epididymis [15]. In older men, acute epididymitis may follow prostatic surgery. Escherichia coli, Proteus spp., K. pneumoniae, and Pseudomonas aeruginosa were occasional causes of the epididymis [14]. Chen et al. [16] reported on two diabetic patients with K. pneumoniae renal abscess and endophthalmitis. In our case, we suggest that the infectious source was the acute epididymitis following the prostatic surgery. However, our patient did not have a history of diabetes mellitus, and no urine specimens for repeated cultures were obtained after a course of systemic antibiotics. Additionally, no other culture-documented
123
sources of infection, such as cardiac vegetation or liver disease, were identified. Despite the early diagnosis and aggressive intravenous and intravitreal antibiotic therapy, the visual outcome of endogenous K. pneumoniae endophthalmitis was extremely poor, with eventual evisceration or enucleation [14, 17]. Nonetheless, early detection of associated infectious focus with initial systemic investigation is the most important factor in the management of endogenous bacterial endophthalmitis because the treatment of the causative organism and control of the infection source would decrease the burden of bacteremia [2]. Ang et al. [14] reported that the clinical features including those caused by more virulent organisms that are risk factors for poor visual outcome. Infections with K1 and K2 capsular serotype, the hypermucoviscosity phenotype, and the presence of the magA gene contributed to the virulence and metastatic nature of K. pneumoniae [14]. Lin et al. [7] demonstrated poor glycemic control to be a risk factor for susceptibility to serotype K1/K2 K. pneumoniae liver abscesses and complication of endophthalmitis. Although we did not examine the serotype of the K. pneumoniae, the magA gene has been reported to be a component of the K1 capsule [18, 19]. Karama et al. [20] reported that a diabetic patient with endogenous endophthalmitis secondary to a liver abscess caused by K. pneumoniae expressed the magA gene. Hunt et al. [21] demonstrated that magA was a virulence factor in experimental K. pneumoniae endophthalmitis. Lin et al. [22] reported that hypermucoviscosity was highly correlated with the presence of the rmpA gene in urinary tract infection strains, and rmpA may play a role in community-acquired urinary tract infections. Because our PCR results were positive for the magA and rmpA genes, K. pneumoniae is an emerging pathogen that caused catastrophic septic ocular complications. In conclusion, the immediate diagnosis and aggressive systemic treatments including vitrectomy and intravitreal antibiotics against K. pneumoniae are most important for the control of sepsis and restoration of vision. PCR analysis of the hypermucoviscosity phenotype may help in understanding the contribution of a distinctive invasive endophthalmitis caused by K. pneumonia.
References 1. Okada AA, Johnson RP, Liles WC, D’Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. 1994;101:832–8. 2. Lee S, Um T, Joe SG, Hwang JU, Kim JG, Yoon YH, Lee JY. Changes in the clinical features and prognostic factors of endogenous endophthalmitis: fifteen years of clinical experience in Korea. Retina. 2012;32:977–84.
J Infect Chemother (2013) 19:326–329 3. Sheu SJ, Kung YH, Wu TT, Chang FP, Horng YH. Risk factors for endogenous endophthalmitis secondary to Klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan. Retina. 2011;31:2026–31. 4. Shankar K, Gyanendra L, Hari S, Narayan SD. Culture proven endogenous bacterial endophthalmitis in apparently healthy individuals. Ocul Immunol Inflamm. 2009;17:396–9. 5. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003;48:403–23. 6. Fung CP, Chang FY, Lee SC, Hu BS, Kuo BI, Liu CY, Ho M, Siu LK. A global emerging disease of Klebsiella pneumoniae liver abscess: is serotype K1 an important factor for complicated endophthalmitis? Gut. 2002;50:420–4. 7. Lin JC, Siu LK, Fung CP, Tsou HH, Wang JJ, Chen CT, et al. Impaired phagocytosis of capsular serotypes K1 or K2 Klebsiella pneumoniae in type 2 diabetes mellitus patients with poor glycemic control. J Clin Endocrinol Metab. 2006;91:3084–7. 8. Yeh KM, Kurup A, Siu LK, Koh YL, Fung CP, Lin JC, et al. Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan. J Clin Microbiol. 2007;45:466–71. 9. Schiedler V, Scott IU, Flynn HW Jr, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004;137:725–31. 10. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology. 2000;107:1483–91. 11. Akasaka K, Tokita S, Koyama A, Ikegami G, Koyama K, Fujihara H, Ichiwata T, Nagao K. A case of septic pulmonary embolism with endogenous endophthalmitis in a healthy adult. Nihon Kokyuki Gakkai Zasshi. 2008;46:291–6. 12. Kodama Y, Yoshitomi T, Hayashi R, Nakagawa R, Ishikawa S. A case of metastatic endophthalmitis associated with liver abscess. Ganka. 1998;40:743–7.
329 13. Kuribayashi S, Ishida T. A case of bilateral metastatic bacterial endophthalmitis. Jpn Rev Clin Ophthalmol. 1991;89:1653–8. 14. Ang M, Jap A, Chee SP. Prognostic factors and outcomes in endogenous Klebsiella pneumoniae endophthalmitis. Am J Ophthalmol. 2011;151:338–44. 15. Luzzi GA, O’Brien TS. Acute epididymitis. BJU Int. 2001;87: 747–55. 16. Chen KJ, Hwang YS, Wang NK, Chao AN. Endogenous Klebsiella pneumoniae endophthalmitis with renal abscess: report of two cases. Int J Infect Dis. 2010;14:e429–32. 17. Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmology. 2007;114:876–80. 18. Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis. 2007;45:284–93. 19. Yeh KM, Chang FY, Fung CP, Lin JC, Siu LK. magA is not a specific virulence gene for Klebsiella pneumoniae strains causing liver abscess but is part of the capsular polysaccharide gene cluster of K. pneumoniae serotype K1. J Med Microbiol. 2006; 55:803–4. 20. Karama EM, Willermain F, Janssens X, Claus M, Van den Wijngaert S, Wang JT, et al. Endogenous endophthalmitis complicating Klebsiella pneumoniae liver abscess in Europe: case report. Int Ophthalmol. 2008;28:111–3. 21. Hunt JJ, Wang JT, Callegan MC. Contribution of mucoviscosityassociated gene A (magA) to virulence in experimental Klebsiella pneumoniae endophthalmitis. Invest Ophthalmol Vis Sci. 2011; 52:6860–6. 22. Lin WH, Wang MC, Tseng CC, Ko WC, Wu AB, Zheng PX, et al. Clinical and microbiological characteristics of Klebsiella pneumoniae isolates causing community-acquired urinary tract infections. Infection. 2010;38:459–64.
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CASE REPORT
Case of endogenous endophthalmitis caused by Klebsiella pneumoniae with magA and rmpA genes in an immunocompetent patient Akira Sawada • Shinya Komori • Kazunari Udo Shinsuke Suemori • Kiyofumi Mochizuki • Mitsuru Yasuda • Kiyofumi Ohkusu
•
Received: 24 May 2012 / Accepted: 10 August 2012 / Published online: 20 September 2012 Ó Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2012
Abstract We report a case of endogenous endophthalmitis caused by Klebsiella pneumoniae in an immunocompetent patient. A 73-year-old man with acute epididymitis who had no history of diabetes mellitus developed endogenous endophthalmitis. The patient underwent anterior vitrectomy and intracapsular cataract extraction with intravitreal injections of both vancomycin and ceftazidime. After the surgery, he was treated with topical and intravenous antibiotics; however, the left eye perforated and was enucleated. Culture from vitreous biopsy specimens grew as K. pneumoniae, which was positive for both magA and rmpA. K. pneumoniae should be considered as a pathogen that can cause severe endogenous endophthalmitis in patients with urinary tract infection. The severity of the disease may be related to the virulence genes. Keywords Endogenous endophthalmitis Klebsiella pneumoniae Acute epididymitis magA rmpA
A. Sawada (&) S. Komori K. Udo S. Suemori K. Mochizuki Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan e-mail: [email protected] M. Yasuda Department of Urology, Gifu University Graduate School of Medicine, Gifu, Japan K. Ohkusu Department of Microbiology, Gifu University Graduate School of Medicine, Gifu, Japan
123
Introduction Endogenous bacterial endophthalmitis results from a blood-borne spread of bacteria with entrance into the intraocular space. It is associated with underlying medical conditions such as diabetes, gastrointestinal disorders, renal failure, heart disease, and malignancies in up to 90 % of the patients [1, 2]. Diabetes is a significant risk factor for the development of endogenous endophthalmitis and poor visual outcome [3]. However, a case series of cultureproven endogenous endophthalmitis has been reported in apparently healthy and immunocompetent individuals [4]. Earlier studies have reported that the most common bacterial organism causing endogenous bacterial endophthalmitis was Staphylococcus aureus [1]. In East Asia, it is more commonly (in 37–70 % of infections) caused by gram-negative organisms, particularly Klebsiella spp. [5]. Among the gram-negative organisms, Klebsiella pneumoniae is known to be the species most frequently responsible for endogenous bacterial endophthalmitis, especially in East Asian countries [2, 5]; e.g., K. pneumoniae was found in 48.4 % of infections [2]. Despite early diagnosis and treatment, the visual prognosis remains poor [1, 2, 5]. Lee et al. [2] reported that K. pneumoniae-associated endogenous endophthalmitis had significantly poorer visual outcomes than those with gram-positive cocci-associated endophthalmitis. Fung et al. [6] reported that K. pneumoniae serotype K1 was significantly associated with liver abscesses with the complication of endophthalmitis. Infections by the K. pneumoniae K1 and K2 capsular serotypes, the mucoid phenotypes, followed by their aerobactin production, were important determinants of virulence [7]. In addition, a close relationship of the mucoviscosity-associated (magA) gene and/or regulator of mucoid phenotype (rmpA) gene to the
J Infect Chemother (2013) 19:326–329
327
K. pneumoniae hypermucoviscosity phenotype has been pointed out [8]. We present here a case of endogenous K. pneumoniae endophthalmitis with acute epididymitis in an immunocompetent patient; both the magA and rmpA genes were identified in vitreous specimens.
Case report A 73-year-old nondiabetic man who had a history of lumbar spinal canal stenosis underwent prostate surgery at another hospital. After the surgery, he was treated with cefdinir (300 mg/day) and loxoprofen, a nonsteroidal antiinflammatory drug. Ten days later, he was examined at an eye clinic because of a 4-day history of blurred vision in the left eye and nausea. His visual acuity was light perception in the left eye and 20/20 in the right eye. The intraocular pressure was 14 mmHg in the right eye and 40 mmHg in the left eye. He was diagnosed with uveitis with secondary glaucoma and was referred to us for further therapy on the same day. Slit-lamp examination showed severe ciliary injection, corneal edema, and severe inflammation with a hypopyon in the anterior chamber of his left eye (Fig. 1). His left fundus could not be examined in detail because of hazy media. Ultrasonography of the posterior segment showed moderately dense infiltrations in the vitreous cavity, and the electroretinogram was completely extinguished in his left eye. His right eye was normal. With a tentative diagnosis of suspected endogenous endophthalmitis, he underwent emergency anterior vitrectomy and intracapsular cataract extraction with intravitreal injections of vancomycin (1 mg/eye) and ceftazidime (2 mg/eye). He was also treated with topical 0.5 % levofloxacin and 0.5 % cefmenoxime, 0.3 % ofloxacin ointment, and intravenous cefpirome (2 g/day). The vitreous aspirate showed a few gram-negative rods. On the following day, we began to determine the primary extraocular origin of the infection because there was no history of ocular trauma and ocular surgery. Physical examination showed a body temperature of 37.2 °C with testicular tenderness. Scrotal magnetic resonance imaging revealed bilateral testicular enlargement and the presence of a moderate hydrocele. No abnormalities were detected by chest roentgenography and computed tomography of the brain, chest, and liver. Laboratory tests demonstrated an elevated leukocyte count of 19,320/ll with 90 % of polymorphonuclear cells, a C-reactive protein level of 16.15 mg/dl, alkaline phosphatase level of 923 IU/l, c-glutamyl-transpeptidase level of 302 IU/l, creatinine level of 1.38 mg/dl, and blood urea nitrogen level of 32.4 mg/ml. The level of hemoglobin A1C was 5.6 %. Urinalysis
Fig. 1 External slit-lamp photograph of the left eye. The conjunctiva is erythematous and chemotic, and the cornea was thickened with inflammatory debris on its endothelium. The anterior chamber is severely irritated with a hypopyon
revealed a pH of 5.5, 1 ? protein, 1 ? white blood cell, 3 ? red blood cells, and 1 ? gram-negative bacilli. These findings led to a diagnosis of acute epididymitis. Two days after admission, the cefpirome was discontinued and replaced by imipenem (1 g/day) for 2 weeks. His ocular inflammation worsened, and the corneal wound ruptured 3 days after the first surgery. With the consent of the patient, his left eye was enucleated 2 days later. The same topical antibiotics were continued after the enucleation. The imipenem was switched to oral levofloxacin 500 mg daily for 7 days. Thereafter, the acute epididymitis gradually improved. Subsequently, cultures from vitreous biopsy specimens obtained during both vitrectomy and enucleation grew K. pneumoniae, which was positive for both the magA and rmpA genes. Polymerase chain reaction (PCR) was performed to amplify the magA and the rmpA genes, as previously described [2]. K. pneumoniae was found to be susceptible to piperacillin, ceftazidime, aztreonam, ceftriaxone, imipenem/cilastatin, amikacin, gentamicin, minocycline, levofloxacin, and vancomycin, and was resistant to sulbactam sodium/ampicillin sodium, and ampicillin (Table 1). Both blood and urine cultures on admission to our hospital were negative.
Discussion Immunocompromised states such as diabetes mellitus, renal failure, and malignancy are associated with a reduced host defense and are risk factors for the development of endogenous endophthalmitis [1, 2, 9, 10]. It has been reported that K. pneumoniae is a common cause of
123
328
J Infect Chemother (2013) 19:326–329
Table 1 Susceptibility testing results of Klebsiella pneumoniae Antimicrobial agent
Minimum inhibitory concentration (lg/ml)
Ampicillin
[16
Piperacillin
B16
Ceftazidime Cefazolin
B1 B8
Cefmetazole
B16
Cefdinir
B1
Imipenem/cilastatin
B1
Aztreonam
B1
Sulbactam/ampicillin
[16
Ceftriaxone
B1
Amikacin
B8
Gentamicin
B2
Cefozopran
B1
Minocycline
B2
Fosfomycin
128
Levofloxacin
B2
Sulfamethoxazole–trimethoprim
B1
Cefpodoxime proxetil
B1
endogenous bacterial endophthalmitis [2]. However, endogenous endophthalmitis caused by K. pneumoniae in immunocompetent patients in Japan is rare, with only three cases reported [11–13]. The mean age of the patients in these reports was 60 years, with a range of 52–71 years. All the cases were men; the primary source of the infection was liver abscess in two cases [12, 13] and septic pulmonary embolism in one case [11]. The visual outcomes in all these cases were poor. Our case was an older man without diabetes mellitus and malignancy, and the outcome was poor. We suggest that delayed diagnosis also leads to poor prognosis [5]. The primary sources of the endogenous K. pneumoniae endophthalmitis were from the hepatobiliary system (77.5 %), followed by the urinary tract (9.9 %), and respiratory system (4.2 %) [14]. Acute epididymitis is characterized by testicular pain and tender swelling of the epididymis [15]. In older men, acute epididymitis may follow prostatic surgery. Escherichia coli, Proteus spp., K. pneumoniae, and Pseudomonas aeruginosa were occasional causes of the epididymis [14]. Chen et al. [16] reported on two diabetic patients with K. pneumoniae renal abscess and endophthalmitis. In our case, we suggest that the infectious source was the acute epididymitis following the prostatic surgery. However, our patient did not have a history of diabetes mellitus, and no urine specimens for repeated cultures were obtained after a course of systemic antibiotics. Additionally, no other culture-documented
123
sources of infection, such as cardiac vegetation or liver disease, were identified. Despite the early diagnosis and aggressive intravenous and intravitreal antibiotic therapy, the visual outcome of endogenous K. pneumoniae endophthalmitis was extremely poor, with eventual evisceration or enucleation [14, 17]. Nonetheless, early detection of associated infectious focus with initial systemic investigation is the most important factor in the management of endogenous bacterial endophthalmitis because the treatment of the causative organism and control of the infection source would decrease the burden of bacteremia [2]. Ang et al. [14] reported that the clinical features including those caused by more virulent organisms that are risk factors for poor visual outcome. Infections with K1 and K2 capsular serotype, the hypermucoviscosity phenotype, and the presence of the magA gene contributed to the virulence and metastatic nature of K. pneumoniae [14]. Lin et al. [7] demonstrated poor glycemic control to be a risk factor for susceptibility to serotype K1/K2 K. pneumoniae liver abscesses and complication of endophthalmitis. Although we did not examine the serotype of the K. pneumoniae, the magA gene has been reported to be a component of the K1 capsule [18, 19]. Karama et al. [20] reported that a diabetic patient with endogenous endophthalmitis secondary to a liver abscess caused by K. pneumoniae expressed the magA gene. Hunt et al. [21] demonstrated that magA was a virulence factor in experimental K. pneumoniae endophthalmitis. Lin et al. [22] reported that hypermucoviscosity was highly correlated with the presence of the rmpA gene in urinary tract infection strains, and rmpA may play a role in community-acquired urinary tract infections. Because our PCR results were positive for the magA and rmpA genes, K. pneumoniae is an emerging pathogen that caused catastrophic septic ocular complications. In conclusion, the immediate diagnosis and aggressive systemic treatments including vitrectomy and intravitreal antibiotics against K. pneumoniae are most important for the control of sepsis and restoration of vision. PCR analysis of the hypermucoviscosity phenotype may help in understanding the contribution of a distinctive invasive endophthalmitis caused by K. pneumonia.
References 1. Okada AA, Johnson RP, Liles WC, D’Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. 1994;101:832–8. 2. Lee S, Um T, Joe SG, Hwang JU, Kim JG, Yoon YH, Lee JY. Changes in the clinical features and prognostic factors of endogenous endophthalmitis: fifteen years of clinical experience in Korea. Retina. 2012;32:977–84.
J Infect Chemother (2013) 19:326–329 3. Sheu SJ, Kung YH, Wu TT, Chang FP, Horng YH. Risk factors for endogenous endophthalmitis secondary to Klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan. Retina. 2011;31:2026–31. 4. Shankar K, Gyanendra L, Hari S, Narayan SD. Culture proven endogenous bacterial endophthalmitis in apparently healthy individuals. Ocul Immunol Inflamm. 2009;17:396–9. 5. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003;48:403–23. 6. Fung CP, Chang FY, Lee SC, Hu BS, Kuo BI, Liu CY, Ho M, Siu LK. A global emerging disease of Klebsiella pneumoniae liver abscess: is serotype K1 an important factor for complicated endophthalmitis? Gut. 2002;50:420–4. 7. Lin JC, Siu LK, Fung CP, Tsou HH, Wang JJ, Chen CT, et al. Impaired phagocytosis of capsular serotypes K1 or K2 Klebsiella pneumoniae in type 2 diabetes mellitus patients with poor glycemic control. J Clin Endocrinol Metab. 2006;91:3084–7. 8. Yeh KM, Kurup A, Siu LK, Koh YL, Fung CP, Lin JC, et al. Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan. J Clin Microbiol. 2007;45:466–71. 9. Schiedler V, Scott IU, Flynn HW Jr, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004;137:725–31. 10. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology. 2000;107:1483–91. 11. Akasaka K, Tokita S, Koyama A, Ikegami G, Koyama K, Fujihara H, Ichiwata T, Nagao K. A case of septic pulmonary embolism with endogenous endophthalmitis in a healthy adult. Nihon Kokyuki Gakkai Zasshi. 2008;46:291–6. 12. Kodama Y, Yoshitomi T, Hayashi R, Nakagawa R, Ishikawa S. A case of metastatic endophthalmitis associated with liver abscess. Ganka. 1998;40:743–7.
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