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Endophthalmitis: An Unusual Presentation of Bacteremia
CASE REPORT
Endophthalmitis: An Unusual Presentation of Bacteremia Pamela Pride, MD, Matthew Nutaitis, MD and Pamela L. Charity, MD
Abstract: Life-threatening diseases can present in benign ways. In this study, a case of endogenous bacterial endophthalmitis, associated with methicillin-resistant Staphylococcus aureus bacteremia, is presented. The patient’s only presenting complaint was pain and redness in his left eye. Ultimately, the patient was diagnosed with an infected pacemaker wire. He did well after treatment with appropriate antibiotics and removal of the infected pacemaker. Endophthalmitis is an unusual complication of systemic bacterial infections with severe consequences if left unrecognized. Patients at high risk for bacteremia (ie, intravenous drug users and hemodialysis patients) who present with ocular complaints should have a thorough funduscopic examination to rule out endophthalmitis. Delay of diagnosis and inappropriate antibiotics are associated with poor outcomes, such as blindness. Key Indexing Terms: Bacterial endophthalmitis; Bacteremia; Metastatic endophthalmitis. [Am J Med Sci 2013;345(1):70–71.]
B
acterial bloodstream infections are often encountered by physicians throughout the world. An uncommon but serious complication is endogenous bacterial endophthalmitis (EBE). EBE occurs when microorganisms gain access to the eye through the bloodstream. We present an interesting case of an endovascular infection presenting solely with monocular complaints of redness, pain and decreased vision. In this study, we discuss the history and physical examination, including ophthalmologic examination, microbiology, treatment and prognosis of EBE. Our purpose is to educate physicians about this unusual complication of a common medical problem.
CASE REPORT A 74 year-old man presented with 1 day of redness and pain in his left eye associated with decreased visual acuity. His medical history was significant for end-stage renal disease requiring hemodialysis, diabetes mellitus, coronary artery disease and ischemic cardiomyopathy status after pacemaker placement. In the past 4 months, the patient was treated twice for methicillin-resistant Staphylococcus aureus (MRSA) dialysis catheter infections. The first infection was treated with removal of the catheter and 2 weeks of vancomycin. The second infection was treated again with removal of the infected catheter and 6 weeks of vancomycin. The patient did well after the second MRSA infection and remained asymptomatic until the day prior of presentation. He had no history of ocular trauma. He did have cataract extraction with intraocular lens placement 2 years before presentation. Because of his new symptoms, he sought medical attention at an academic ophthalmology clinic. On ophthalmologic examination, the visual acuity was 20/40 in From the Department of Internal Medicine (PP, PLC), General Internal Medicine Division, Department of Ophthalmology (MN), Medical University of South Carolina, Charleston, South Carolina. Submitted January 25, 2012; accepted in revised form May 15, 2012. The authors have no conflicts of interest. This case was presented in a poster format at the Society of Hospital Medicine national meeting in May 2007. Correspondence: Pamela Pride, MD, Medical University of South Carolina, 135 Rutledge Avenue, MSC 591, Charleston, SC 29425-5910 (E-mail: [email protected]).
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the right eye and counting fingers in the left eye. Intraocular pressures were normal in both eyes, specifically 12 mm Hg in the right eye and 13 mm Hg in the left eye. Anterior segment examination revealed injected conjunctiva, slight corneal edema, 4+ anterior chamber cells with layered hypopyon (Figure 1) and a well-centered posterior chamber intraocular lens. Posterior segment evaluation discovered a poor view through vitreous cell to the retina (Figure 2). Retinal exudates were noted. The differential diagnosis included various inflammatory eye conditions, such as scleritis, episcleritis, keratitis and uveitis. However, in the absence of recent ocular surgery or trauma, the clinical presentation and examination findings were most consistent with panuveitis. Ophthalmologic examination ruled out occult foreign body and occult trauma, which are potential causes of panuveitis. With this patient’s medical history, EBE was considered the most likely diagnosis. The ophthalmology service performed a vitreous tap with histological evaluation and culture and recommended admission to general medicine to investigate the underlying cause of EBE in this patient. At the time of admission to the general medical service, his physical examination was significant for temperature 97.6°C, heart rate 72 beats per minute and blood pressure 136/58 mm Hg. In general, he was a well-appearing, age-appropriate white man in no apparent distress. Ophthalmologic examination was as noted previously. His chest was clear to auscultation bilaterally. A tunneled hemodialysis catheter was in his right anterior chest wall; the exit site was nonerythematous, nontender and without purulent discharge. Cardiovascular examination was normal, including absence of murmurs and jugular venous distention. The remainder of his examination was unremarkable. Laboratory data on admission were significant for blood urea nitrogen of 48 mg/dL and creatinine of 3.2 mg/dl, white blood cell count was normal and hemoglobin level was 10.2 g/dL. Upon admission to the hospital, further workup for the cause of EBE began. Initial studies included blood cultures, erythrocyte sedimentation rate and syphilis serologies. Blood cultures grew MRSA; all other mentioned studies were unrevealing. The patient was initially placed on vancomycin and his dialysis catheter was
FIGURE 1. External ocular examination showing injected sclera and hypopyon.
The American Journal of the Medical Sciences
Volume 345, Number 1, January 2013
Endophthalmitis
FIGURE 2. Fundoscopic examination showing vitreal inflammation and debris.
removed. Infectious disease consultants recommended ruling out endocarditis and switching antibiotics to daptomycin. Transesophageal echocardiogram revealed vegetation on one of his pacemaker wires (Figure 3). The patient’s pacemaker was removed without complication and he was discharged home on daptomycin for 6 weeks. The patient did well and had a new pacemaker implanted after completion of antibiotics.
DISCUSSION Endophthalmitis, classified as either endogenous or exogenous, is infection and inflammation of the posterior segment of the eye, a site of immunologic inactivity.1 Exogenous bacterial endophthalmitis occurs when the external ocular surface is compromised, either from surgery or from trauma. EBE occurs when microorganisms gain access to the eye through the bloodstream. Endogenous cases account for ,10% of bacterial endophthalmitis. EBE is almost always associated with
underlying chronic medical illnesses such as diabetes, heart disease or malignancy.2 Examination findings typically include anterior and posterior chamber inflammation, elevated intraocular pressure, and injected conjunctiva. As in our patient, fundoscopic examination can be difficult because of vitreal inflammation but remains an important diagnostic tool in bacteremic patients with visual complaints. As in this case, EBE is monocular in 85% percent of cases.2 Blood culture is the most reliable way to confirm the diagnosis and find the causative organism. In one case series, blood cultures had a sensitivity of 74% compared with intraocular culture sensitivity of 56%.2 Cases of EBE demonstrate an interesting geographic variance in the microbiology. In East Asia, there is a strong predilection of gram-negative infections, particularly Klebsiella in association with hepatobiliary infections.3 In the United States, gram-positive organisms account for the majority of EBE cases, usually related to endovascular infections, septic arthritis, or skin and soft tissue infections.2 Unlike exogenous bacterial endophthalmitis, the treatment of EBE has never been studied in a controlled trial. Results of the Endophthalmitis Vitrectomy Study favor intraocular antibiotics over systemic antibiotics and pars plana vitrectomy for patients with poor visual acuity on presentation.4 However, this study enrolled only patients with exogenous endophthalmitis; thus, it is unclear if these results can be generalized to patients with EBE. As such, systemic antibiotics are considered the cornerstone of therapy for EBE. Adjuvant therapy includes intravitreal antibiotics, intravitreal steroids and vitrectomy. However, use of these modalities remains controversial because of lack of clear supporting evidence. The duration of therapy is driven by the underlying bacterial infection. The visual outcome of EBE can be dismal. A review of the literature since 1986 indicates that 44% of patients suffer blindness and 25% of patients require evisceration or enucleation. Delay of diagnosis and inappropriate antibiotics are associated with worse outcomes.2 In conclusion, this case illustrates how life-threatening diseases can present in seemingly benign ways. Endophthalmitis is an unusual complication of systemic bacterial infections with severe consequences if left unrecognized. Patients at high risk for bacteremia (ie, intravenous drug users and hemodialysis patients) who present with ocular complaints should have a thorough funduscopic examination to rule out endophthalmitis. REFERENCES 1. Taylor AW. Ocular immune privilege. Eye 2009;23:1885–9. 2. Jackson TL, Eykyn S, Graham EM, et al. Endogenous bacterial endophthalmitis: a 17 year prospective series and review of 267 reported cases. Surv Ophthalmol 2003;48:403–23. 3. Wong JS, Chan TK, Lee HM, et al. Endogenous bacterial endophthalmitis. An East Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology 2000;107:1483–91.
FIGURE 3. Echocardiography showing vegetation on pacemaker lead.
Ó 2013 Lippincott Williams & Wilkins
4. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479–96.
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Endophthalmitis: An Unusual Presentation of Bacteremia Pamela Pride, MD, Matthew Nutaitis, MD and Pamela L. Charity, MD
Abstract: Life-threatening diseases can present in benign ways. In this study, a case of endogenous bacterial endophthalmitis, associated with methicillin-resistant Staphylococcus aureus bacteremia, is presented. The patient’s only presenting complaint was pain and redness in his left eye. Ultimately, the patient was diagnosed with an infected pacemaker wire. He did well after treatment with appropriate antibiotics and removal of the infected pacemaker. Endophthalmitis is an unusual complication of systemic bacterial infections with severe consequences if left unrecognized. Patients at high risk for bacteremia (ie, intravenous drug users and hemodialysis patients) who present with ocular complaints should have a thorough funduscopic examination to rule out endophthalmitis. Delay of diagnosis and inappropriate antibiotics are associated with poor outcomes, such as blindness. Key Indexing Terms: Bacterial endophthalmitis; Bacteremia; Metastatic endophthalmitis. [Am J Med Sci 2013;345(1):70–71.]
B
acterial bloodstream infections are often encountered by physicians throughout the world. An uncommon but serious complication is endogenous bacterial endophthalmitis (EBE). EBE occurs when microorganisms gain access to the eye through the bloodstream. We present an interesting case of an endovascular infection presenting solely with monocular complaints of redness, pain and decreased vision. In this study, we discuss the history and physical examination, including ophthalmologic examination, microbiology, treatment and prognosis of EBE. Our purpose is to educate physicians about this unusual complication of a common medical problem.
CASE REPORT A 74 year-old man presented with 1 day of redness and pain in his left eye associated with decreased visual acuity. His medical history was significant for end-stage renal disease requiring hemodialysis, diabetes mellitus, coronary artery disease and ischemic cardiomyopathy status after pacemaker placement. In the past 4 months, the patient was treated twice for methicillin-resistant Staphylococcus aureus (MRSA) dialysis catheter infections. The first infection was treated with removal of the catheter and 2 weeks of vancomycin. The second infection was treated again with removal of the infected catheter and 6 weeks of vancomycin. The patient did well after the second MRSA infection and remained asymptomatic until the day prior of presentation. He had no history of ocular trauma. He did have cataract extraction with intraocular lens placement 2 years before presentation. Because of his new symptoms, he sought medical attention at an academic ophthalmology clinic. On ophthalmologic examination, the visual acuity was 20/40 in From the Department of Internal Medicine (PP, PLC), General Internal Medicine Division, Department of Ophthalmology (MN), Medical University of South Carolina, Charleston, South Carolina. Submitted January 25, 2012; accepted in revised form May 15, 2012. The authors have no conflicts of interest. This case was presented in a poster format at the Society of Hospital Medicine national meeting in May 2007. Correspondence: Pamela Pride, MD, Medical University of South Carolina, 135 Rutledge Avenue, MSC 591, Charleston, SC 29425-5910 (E-mail: [email protected]).
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the right eye and counting fingers in the left eye. Intraocular pressures were normal in both eyes, specifically 12 mm Hg in the right eye and 13 mm Hg in the left eye. Anterior segment examination revealed injected conjunctiva, slight corneal edema, 4+ anterior chamber cells with layered hypopyon (Figure 1) and a well-centered posterior chamber intraocular lens. Posterior segment evaluation discovered a poor view through vitreous cell to the retina (Figure 2). Retinal exudates were noted. The differential diagnosis included various inflammatory eye conditions, such as scleritis, episcleritis, keratitis and uveitis. However, in the absence of recent ocular surgery or trauma, the clinical presentation and examination findings were most consistent with panuveitis. Ophthalmologic examination ruled out occult foreign body and occult trauma, which are potential causes of panuveitis. With this patient’s medical history, EBE was considered the most likely diagnosis. The ophthalmology service performed a vitreous tap with histological evaluation and culture and recommended admission to general medicine to investigate the underlying cause of EBE in this patient. At the time of admission to the general medical service, his physical examination was significant for temperature 97.6°C, heart rate 72 beats per minute and blood pressure 136/58 mm Hg. In general, he was a well-appearing, age-appropriate white man in no apparent distress. Ophthalmologic examination was as noted previously. His chest was clear to auscultation bilaterally. A tunneled hemodialysis catheter was in his right anterior chest wall; the exit site was nonerythematous, nontender and without purulent discharge. Cardiovascular examination was normal, including absence of murmurs and jugular venous distention. The remainder of his examination was unremarkable. Laboratory data on admission were significant for blood urea nitrogen of 48 mg/dL and creatinine of 3.2 mg/dl, white blood cell count was normal and hemoglobin level was 10.2 g/dL. Upon admission to the hospital, further workup for the cause of EBE began. Initial studies included blood cultures, erythrocyte sedimentation rate and syphilis serologies. Blood cultures grew MRSA; all other mentioned studies were unrevealing. The patient was initially placed on vancomycin and his dialysis catheter was
FIGURE 1. External ocular examination showing injected sclera and hypopyon.
The American Journal of the Medical Sciences
Volume 345, Number 1, January 2013
Endophthalmitis
FIGURE 2. Fundoscopic examination showing vitreal inflammation and debris.
removed. Infectious disease consultants recommended ruling out endocarditis and switching antibiotics to daptomycin. Transesophageal echocardiogram revealed vegetation on one of his pacemaker wires (Figure 3). The patient’s pacemaker was removed without complication and he was discharged home on daptomycin for 6 weeks. The patient did well and had a new pacemaker implanted after completion of antibiotics.
DISCUSSION Endophthalmitis, classified as either endogenous or exogenous, is infection and inflammation of the posterior segment of the eye, a site of immunologic inactivity.1 Exogenous bacterial endophthalmitis occurs when the external ocular surface is compromised, either from surgery or from trauma. EBE occurs when microorganisms gain access to the eye through the bloodstream. Endogenous cases account for ,10% of bacterial endophthalmitis. EBE is almost always associated with
underlying chronic medical illnesses such as diabetes, heart disease or malignancy.2 Examination findings typically include anterior and posterior chamber inflammation, elevated intraocular pressure, and injected conjunctiva. As in our patient, fundoscopic examination can be difficult because of vitreal inflammation but remains an important diagnostic tool in bacteremic patients with visual complaints. As in this case, EBE is monocular in 85% percent of cases.2 Blood culture is the most reliable way to confirm the diagnosis and find the causative organism. In one case series, blood cultures had a sensitivity of 74% compared with intraocular culture sensitivity of 56%.2 Cases of EBE demonstrate an interesting geographic variance in the microbiology. In East Asia, there is a strong predilection of gram-negative infections, particularly Klebsiella in association with hepatobiliary infections.3 In the United States, gram-positive organisms account for the majority of EBE cases, usually related to endovascular infections, septic arthritis, or skin and soft tissue infections.2 Unlike exogenous bacterial endophthalmitis, the treatment of EBE has never been studied in a controlled trial. Results of the Endophthalmitis Vitrectomy Study favor intraocular antibiotics over systemic antibiotics and pars plana vitrectomy for patients with poor visual acuity on presentation.4 However, this study enrolled only patients with exogenous endophthalmitis; thus, it is unclear if these results can be generalized to patients with EBE. As such, systemic antibiotics are considered the cornerstone of therapy for EBE. Adjuvant therapy includes intravitreal antibiotics, intravitreal steroids and vitrectomy. However, use of these modalities remains controversial because of lack of clear supporting evidence. The duration of therapy is driven by the underlying bacterial infection. The visual outcome of EBE can be dismal. A review of the literature since 1986 indicates that 44% of patients suffer blindness and 25% of patients require evisceration or enucleation. Delay of diagnosis and inappropriate antibiotics are associated with worse outcomes.2 In conclusion, this case illustrates how life-threatening diseases can present in seemingly benign ways. Endophthalmitis is an unusual complication of systemic bacterial infections with severe consequences if left unrecognized. Patients at high risk for bacteremia (ie, intravenous drug users and hemodialysis patients) who present with ocular complaints should have a thorough funduscopic examination to rule out endophthalmitis. REFERENCES 1. Taylor AW. Ocular immune privilege. Eye 2009;23:1885–9. 2. Jackson TL, Eykyn S, Graham EM, et al. Endogenous bacterial endophthalmitis: a 17 year prospective series and review of 267 reported cases. Surv Ophthalmol 2003;48:403–23. 3. Wong JS, Chan TK, Lee HM, et al. Endogenous bacterial endophthalmitis. An East Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology 2000;107:1483–91.
FIGURE 3. Echocardiography showing vegetation on pacemaker lead.
Ó 2013 Lippincott Williams & Wilkins
4. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479–96.
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