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Escherichia coli emphysematous endophthalmitis and pyelonephritis
Escherichia coli Emphysematod Pyelonephritis
Endophthalmitis and
Case Report and Review of the Literature
RAFAT FARAAWI, M.B., Ch.B. IGNATIUS W. FONG, M.B., B.S., F.R.C.P.(C) Toronto, Ontario,
Emphysematous Escherichia coli endophthalmitis occurred in a 72year-old patient as a complication of E. coli septicemia secondary to emphysematous pyelonephritis and endocarditis. This is the first reported case of endogenous qmphysematous endophthalmitii secondary to E. coli septicemia.
Canada
Bacterial endophthalmitis is a rare complication of bacteremia; moreover, emphysematous endophthalmitis (the presence of gas in the ocular globe) has never before been described in the English literature. A unique case is herein reported with three extremely rare complications of Escherichia coli infection in a diabetic patient: emphysematous pyelonephritis, endophthalmitis, and bacterial endocarditis. A review of the literature and a detailed discussion on the first two complications are presented after the case report. CASE REPORT
From St. Michael’s Hospital,bepartment of Medicine, University of Toronto, Toronto, Ontario, Canada. Requests for reprints should be addressed to Dr. lgnatius W. Fong, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8. Manuscript submitted October 8, 1987, and accepted in revised form January 5, 1988.
636
March
1966
The American
Journal
A 72-year-old female patient with a long-standing history of type II diabetes mellitus, coronary artery disease, and hypertension presented in February 1987 with fever, right flank pain, and collapse. On initial presentation, there was no history of visual disturbance and no abnormalities of the eyes were noted. The results of an eye examination three months previously were normal. Blood and urine cultures grew E. coli, and the patient was treated with intravenous ampicillin and tobramycin. Plain radiographic views (Figure 1) and computerized tomography (CT scan) of the abdomen revealed gas in the right renal parenchyma and renal pelvis diagnostic of emphysematous pyelonephritis, and she subsequently underwent right nephrectomy. Pathologic examination revealed acute necrotizing pyelonephritis with intrarenal abscess and perinephric abscess. Cultures of the kidney grew E. coli. On the fourth hospital day, the patient’s condition deteriorated with obtundation and she responded only to deep pain with no focal neurologic findings or meningismus. Examination of the eye revealed swelling of the right eyelids with conjunctival injection and edema and cloudiness of the anterior chamber, but no obvious gas bubbles. A CT scan of the head (to exclude intracranial lesions) showed gas in the right globe (Figure 2), indicating the presence of emphysematous endophthalmitis. Vitrectomy was performed and treatment also included intravitreous gentamicin, fortified topical gentamicin drops, and intravenous cefotaxime, but there was no improvement in vision. The vitreous aspirate grew E. coli and, eventually, right eye enucleation was carried out. The antimicrobial sensitivity of the organism was the same as those of the isolates from blood, urine, and kidney. Approximately three weeks after admission, she had sudden onset of congestive heart failure with mitral regurgitation, and an echocardiogram showed vegetations on the mitral valve. The patient underwent emergency
of Medicine
Volume
64
ENDOPHTHALMITIS
AND
PYELONEPHRITIS-FARAAWI
and FONG
Endophthalmitis is a severe inflammation of the ocular cavities (anterior and posterior segments) and their lining tissues, usually associated with focal purulence. The infection can be exogenous or primary in origin, usually as a complication of surgery or accidental injury. Endophthalmitis is most commonly seen postoperatively, and the organisms most frequently involved include Staphylococcus epidermidis and Staphylococcus aureus, followed by gram-negative bacilli, including Pseudomonas aeruginosa. Endogenous or secondary endophthalmitis is extremely rare and results from fungemia or bacteremia caused by infection at other organ sites. It is most commonly seen in association with disseminated candidiasis. Urinary tract infection as a primary source accounts for most of the reported cases of endogenous gram-negative bacterial endophthalmitis. Other sources include meningitis, endocarditis, and soft tissue infections, but these are more commonly secondary to staphylococcal or streptococcal infections. E. coli endophthalmitis rarely complicates E. coli septicemia. A search of the literature over the last 20 years showed only four reported cases, none of which had gas in the eye globe [l-4]. This is the first reported case with emphysematous endophthalmitis secondary to an endogenous source. This was detected by a CT scan of the head, which was ordered to exclude an intracranial mass lesion. None of the reported cases mentioned any radiologic investigation of the head; thus, gas in the eye globe could have been missed. Small gas bubbles can sometimes be detected clinically in the anterior chamber after vitreous aspiration, and these represent introduced air. The mechanism of gas formation in this condition could be explained based on the same mechanism of emphysematous pyelonephritis. Most likely, a high concentration of glucose in the eye tissue provides a substrate for
Figure 1. Plain abdominal radiograph shows the presence of gas in the parenchyma and pelvis of the right kidney.
cardiac surgery at which time her mitral valve was replaced. At surgery, a large abscess was found on the posterior mitral leaflet and the anterior leaflet was redundant. Pathologic findings included inflammation with myxomatous changes, but the Gram stain and cultures of the valve were negative. Antibiotics were continued for a total of six weeks. The patient had an excellent recovery from surgery and was discharged.
METHODS The literature search was accomplished by: (1) Medline computer search; (2) review of Index Medicus; and (3) references from textbooks and journals. Key words used for reference included: gram-negative endophthalmitis, E. coli endophthalmitis, emphysematous endophthalmitis, and emphysematous pyelonephritis. In addition, the general literature on endophthalmitis and pyelonephritis was reviewed.
COMMENTS This case represents three rare, life-threatening infectious complications of E. coli infection, namely emphysematous pyelonephritis, emphysematous endophthalmitis, and endocarditis.
Figure 2. A CT scan of the orbits demonstrating ence of gas in the right globe.
March
1988
The American
Journal
of Medicine
Volume
the pres-
84
697
ENDOPHTHALMITIS
TABLE
I
AND
PYELONEPHRITIS-FARAAWI
Demographic
Patient”
and Clinical
and
Features
Age
Sex
2
62 66
M F
Pyelonephritis Pyelonephritis
3 4 5
70 56 72
M
Pyelonephritis Gangrenous Pyelonephritis
1
* Patients
1 through
F
F 4 were
described
FONG
of Patients
Underlying Condition
Primary Source
toe
in the literature;
with E. coli Endophthalmitis
Patient
Diabetes Diabetes
mellitus mellitus
Bilateral Bilateral
Diabetes Diabetes Diabetes
mellitus mellitus mellitus
Unilateral Bilateral Unilateral
6 is the current
March
1966
The American
Journal
of Medicine
Volume
Outcome Loss of sight Incomplete loss of sight Loss of sight Loss of sight Loss of sight
Gas Formatlon None None None None Present
case.
present in the globe. This may be suspected clinically by the appearance of a gas bubble on eye examination, although this was not detected in the current case. However, since gram-negative endophthalmitis is an ocular emergency with the potential for rapid progression, definitive treatment should not be delayed by CT scanning and a plain radiograph might be sufficient. Emphysematous pyelonephritis is a rare necrotizing infection of renal parenchyma and perirenal tissue. It occurs mainly in diabetic patients with or without underlying ureteral obstruction. The causative organisms are gasproducing types, most commonly E. coli. Klein et al [7] reviewed 66 cases reported in the medical literature. All patients had underlying diabetes mellitus. The most common organism by far was E. coli (68 percent), followed by Klebsiella species (9 percent), whereas multiple organisms were present in 14 percent. The origin of gas in emphysematous pyelonephritis remains controversial. Most of the reports [8,9] suggested that a high glucose level in tissue provides a substrate for bacteria to produce carbon dioxide and hydrogen by fermentation of sugar. Another factor that may account for the development of this entity is impaired tissue and vascular response of the host caused by necrotizing infection. Organisms capable of producing carbon dioxide then use necrotic tissue as a substrate in vivo to generate gas. Patients usually present with severe chills, fever, flank pain [lo] and, frequently, sepsis. Diagnosis is usually established by noting the presence of gas in renal parenchyma by abdominal plain radiographic films, ultrasound, or abdominal CT scans. Gas confined to the collecting system may be seen in a more benign condition, emphysematous pyelitis, most often in association with urinary tract obstruction [ 1 I]. Air can also be introduced into the urinary tract by surgery, trauma, or a fistula communicating with the intestines. Management includes aggressive resuscitation, control of diabetes, and broad-spectrum antibiotics, followed in the majority of cases by nephrectomy. The prognosis of this entity depends on early recognition of the condition, treatment, and type of management (whether surgical, medical, or combined). The overall mortality is 38 per-
bacteria to produce carbon dioxide and hydrogen by fermentation. In the five cases now reported, E. coli was recovered from the primary source, blood, and vitreous aspirate in all the cases. All five cases had underlying diabetes mellitus. The primary source was pyelonephritis in four patients and gangrenous toe in the remaining case. Four of the cases had complete loss of vision in the affected eyes and one had marked diminution of vision (Table I). Clinically, patients with endogenous endophthalmitis usually complain of ocular pain and decreased vision. Other symptoms (as a result of the septicemia) include malaise, fever, and headache. Ophthalmologic findings include conjunctival edema and injection, hazy cornea, hypopyon, and upper lid edema. Because endogenous eye infection can be rapidly devastating with loss of vision, suspected cases should have immediate vitreous aspiration for culture and Gram stain. Both parenteral and intravitreous antibiotics should be administered [5] and subconjunctival or sub-Tenon’s injections and fortified topical antibiotics are commonly used. Vitrectomy has also been recommended to evacuate vitreal abscess and prevent the need for enucleation. Despite advances in antimicrobial therapy, the prognosis fOt’ restoration of vision is poor in gram-negative bacterial endophthalmitis. Endogenous bacterial endophthalmitis should be suspected as a complication of all cases of septicemia with the occurrence of clouding of vision and ocular pain, particularly in elderly patients with underlying diabetes. It is also important to know that, rarely, endophthalmitis could be the initial manifestation of septicemia. A search for the primary site of infection and early treatment with antibiotics may improve the prognosis of this rare complication of septicemia. Gram-negative endophthalmitis is associated with an extremely poor prognosis compared with gram-positive endophthalmitis, which has a relatively good prognosis [6]. For this reason, the recognition of intraocular gas is important, as this clue indicates a form of endophthalmitis requiring very aggressive management. Radiographic examination of the eye in septic patients with clinical evidence of endophthalmitis may be a useful tool in detecting coliform infection if gas is
636
Site
64
ENDOPHTHALMITIS
cent, with only a 29 percent survival rate for those treated medically, compared with a 71 percent rate for those given both medical and surgical treatment. Gram-negative bacterial endocarditis is a very rare disease and narcotic addicts, prosthetic valve recipients, and patients with cirrhosis are at increased risk for this condition. Congestive heart failure is common and the prognosis is poor, with mortality rates of 75 to 83 percent [ 121. The patient currently described had none of the increased risk factors for gram-negative bacterial endocarditis and survived despite the other major complications and underlying diabetes mellitus. In early reports, Salmonella species were the most common Enterobacteriaceae causing endocarditis but, of the other species, E. coli was the leading cause of endocarditis in a review of 44 cases [ 131. In some cities, P. aeruginosa and Serratia marcescens are the major pathogens causing endocarditis in narcotic addicts.
PYELONEPHRITIS-FARAAWI
and
FONG
REFERENCES 1, 2. 3.
4. 5.
6. 7. 8.
9. 10.
CONCLUSION This case is unique in having both emphysematous pyelonephritis and endophthalmitis. Most likely, the mechanism of gas production was the same. Early diagnosis and management are important in both conditions. Likewise, both might require combined surgical and medical treatment.
AND
11, 12.
13.
March 1988
Zakka K, Hirose T: Bilateral endogenous E. coli endophthalmitis. Ann Ophthalmol 1985; 17: 212-215. Cohen P, Kirshner J, Whiting G: Bilateral endogenous E. coli endophthalmitis. Arch Intern Med 1980; 140: 1088-1089. Fanning WL, Stubbert J, Irwin ES, Aronson MD: A case of bilateral E. coli endophthalmitis. Am J Med 1976; 61: 295-297. Shammas HF: Endogenous E. coli endophthalmitis. Surv Ophthalmol 1977; 21: 429-435. Graham RO, Peyman GA, Fishman G: lntravitreal injection of cephaloridine in the treatment of endophthalmitis. Arch Ophthalmol 1975; 93: 56-61. Mandelbaum S, Foster RK: Postoperative endophthalmitis. Int Ophthalmol Clin 1987; 27: 95-106. Klein FA, Smith MJV, Vick CW Ill, Schneider V: Emphysematous pyelonephritis. South Med J 1986; 79: 41-46. Clifford NJ, Katz I: Subcutaneous emphysema complicating renal infection by gas-forming coliform bacteria. N Engl J Med 1962; 266: 437-439. Ireland GW, Javadpour N, Cass AS: Renal emphysema and retention of renal function. J Urol 1971; 106: 463-466. Michaeli J. Moale P. Perlbera S. Heimaw S. Caine M: Emohvsematous pie1onephritis.J Ural 1984; i31: 203-208. . Evanoff GV, Thompson CS, Foley R, Weinman EJ: Spectrum of gas within the kidney. Am J Med 1987; 83: 149-154. Schield WM, Sande MA: Endocarditis and intravascular infections. In: Mandell GC, Douglas JR, Bennett JE, eds. Principles and practice of infectious disease. New York: John Wiley and Sons, 1979; 667-668. Carruthers M: Endocarditis due to enteric bacilli other than Salmonellae. Am J Med 1973; 55: 811-818.
The American
Journal
of Medicine
Volume
84
639
Endophthalmitis and
Case Report and Review of the Literature
RAFAT FARAAWI, M.B., Ch.B. IGNATIUS W. FONG, M.B., B.S., F.R.C.P.(C) Toronto, Ontario,
Emphysematous Escherichia coli endophthalmitis occurred in a 72year-old patient as a complication of E. coli septicemia secondary to emphysematous pyelonephritis and endocarditis. This is the first reported case of endogenous qmphysematous endophthalmitii secondary to E. coli septicemia.
Canada
Bacterial endophthalmitis is a rare complication of bacteremia; moreover, emphysematous endophthalmitis (the presence of gas in the ocular globe) has never before been described in the English literature. A unique case is herein reported with three extremely rare complications of Escherichia coli infection in a diabetic patient: emphysematous pyelonephritis, endophthalmitis, and bacterial endocarditis. A review of the literature and a detailed discussion on the first two complications are presented after the case report. CASE REPORT
From St. Michael’s Hospital,bepartment of Medicine, University of Toronto, Toronto, Ontario, Canada. Requests for reprints should be addressed to Dr. lgnatius W. Fong, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8. Manuscript submitted October 8, 1987, and accepted in revised form January 5, 1988.
636
March
1966
The American
Journal
A 72-year-old female patient with a long-standing history of type II diabetes mellitus, coronary artery disease, and hypertension presented in February 1987 with fever, right flank pain, and collapse. On initial presentation, there was no history of visual disturbance and no abnormalities of the eyes were noted. The results of an eye examination three months previously were normal. Blood and urine cultures grew E. coli, and the patient was treated with intravenous ampicillin and tobramycin. Plain radiographic views (Figure 1) and computerized tomography (CT scan) of the abdomen revealed gas in the right renal parenchyma and renal pelvis diagnostic of emphysematous pyelonephritis, and she subsequently underwent right nephrectomy. Pathologic examination revealed acute necrotizing pyelonephritis with intrarenal abscess and perinephric abscess. Cultures of the kidney grew E. coli. On the fourth hospital day, the patient’s condition deteriorated with obtundation and she responded only to deep pain with no focal neurologic findings or meningismus. Examination of the eye revealed swelling of the right eyelids with conjunctival injection and edema and cloudiness of the anterior chamber, but no obvious gas bubbles. A CT scan of the head (to exclude intracranial lesions) showed gas in the right globe (Figure 2), indicating the presence of emphysematous endophthalmitis. Vitrectomy was performed and treatment also included intravitreous gentamicin, fortified topical gentamicin drops, and intravenous cefotaxime, but there was no improvement in vision. The vitreous aspirate grew E. coli and, eventually, right eye enucleation was carried out. The antimicrobial sensitivity of the organism was the same as those of the isolates from blood, urine, and kidney. Approximately three weeks after admission, she had sudden onset of congestive heart failure with mitral regurgitation, and an echocardiogram showed vegetations on the mitral valve. The patient underwent emergency
of Medicine
Volume
64
ENDOPHTHALMITIS
AND
PYELONEPHRITIS-FARAAWI
and FONG
Endophthalmitis is a severe inflammation of the ocular cavities (anterior and posterior segments) and their lining tissues, usually associated with focal purulence. The infection can be exogenous or primary in origin, usually as a complication of surgery or accidental injury. Endophthalmitis is most commonly seen postoperatively, and the organisms most frequently involved include Staphylococcus epidermidis and Staphylococcus aureus, followed by gram-negative bacilli, including Pseudomonas aeruginosa. Endogenous or secondary endophthalmitis is extremely rare and results from fungemia or bacteremia caused by infection at other organ sites. It is most commonly seen in association with disseminated candidiasis. Urinary tract infection as a primary source accounts for most of the reported cases of endogenous gram-negative bacterial endophthalmitis. Other sources include meningitis, endocarditis, and soft tissue infections, but these are more commonly secondary to staphylococcal or streptococcal infections. E. coli endophthalmitis rarely complicates E. coli septicemia. A search of the literature over the last 20 years showed only four reported cases, none of which had gas in the eye globe [l-4]. This is the first reported case with emphysematous endophthalmitis secondary to an endogenous source. This was detected by a CT scan of the head, which was ordered to exclude an intracranial mass lesion. None of the reported cases mentioned any radiologic investigation of the head; thus, gas in the eye globe could have been missed. Small gas bubbles can sometimes be detected clinically in the anterior chamber after vitreous aspiration, and these represent introduced air. The mechanism of gas formation in this condition could be explained based on the same mechanism of emphysematous pyelonephritis. Most likely, a high concentration of glucose in the eye tissue provides a substrate for
Figure 1. Plain abdominal radiograph shows the presence of gas in the parenchyma and pelvis of the right kidney.
cardiac surgery at which time her mitral valve was replaced. At surgery, a large abscess was found on the posterior mitral leaflet and the anterior leaflet was redundant. Pathologic findings included inflammation with myxomatous changes, but the Gram stain and cultures of the valve were negative. Antibiotics were continued for a total of six weeks. The patient had an excellent recovery from surgery and was discharged.
METHODS The literature search was accomplished by: (1) Medline computer search; (2) review of Index Medicus; and (3) references from textbooks and journals. Key words used for reference included: gram-negative endophthalmitis, E. coli endophthalmitis, emphysematous endophthalmitis, and emphysematous pyelonephritis. In addition, the general literature on endophthalmitis and pyelonephritis was reviewed.
COMMENTS This case represents three rare, life-threatening infectious complications of E. coli infection, namely emphysematous pyelonephritis, emphysematous endophthalmitis, and endocarditis.
Figure 2. A CT scan of the orbits demonstrating ence of gas in the right globe.
March
1988
The American
Journal
of Medicine
Volume
the pres-
84
697
ENDOPHTHALMITIS
TABLE
I
AND
PYELONEPHRITIS-FARAAWI
Demographic
Patient”
and Clinical
and
Features
Age
Sex
2
62 66
M F
Pyelonephritis Pyelonephritis
3 4 5
70 56 72
M
Pyelonephritis Gangrenous Pyelonephritis
1
* Patients
1 through
F
F 4 were
described
FONG
of Patients
Underlying Condition
Primary Source
toe
in the literature;
with E. coli Endophthalmitis
Patient
Diabetes Diabetes
mellitus mellitus
Bilateral Bilateral
Diabetes Diabetes Diabetes
mellitus mellitus mellitus
Unilateral Bilateral Unilateral
6 is the current
March
1966
The American
Journal
of Medicine
Volume
Outcome Loss of sight Incomplete loss of sight Loss of sight Loss of sight Loss of sight
Gas Formatlon None None None None Present
case.
present in the globe. This may be suspected clinically by the appearance of a gas bubble on eye examination, although this was not detected in the current case. However, since gram-negative endophthalmitis is an ocular emergency with the potential for rapid progression, definitive treatment should not be delayed by CT scanning and a plain radiograph might be sufficient. Emphysematous pyelonephritis is a rare necrotizing infection of renal parenchyma and perirenal tissue. It occurs mainly in diabetic patients with or without underlying ureteral obstruction. The causative organisms are gasproducing types, most commonly E. coli. Klein et al [7] reviewed 66 cases reported in the medical literature. All patients had underlying diabetes mellitus. The most common organism by far was E. coli (68 percent), followed by Klebsiella species (9 percent), whereas multiple organisms were present in 14 percent. The origin of gas in emphysematous pyelonephritis remains controversial. Most of the reports [8,9] suggested that a high glucose level in tissue provides a substrate for bacteria to produce carbon dioxide and hydrogen by fermentation of sugar. Another factor that may account for the development of this entity is impaired tissue and vascular response of the host caused by necrotizing infection. Organisms capable of producing carbon dioxide then use necrotic tissue as a substrate in vivo to generate gas. Patients usually present with severe chills, fever, flank pain [lo] and, frequently, sepsis. Diagnosis is usually established by noting the presence of gas in renal parenchyma by abdominal plain radiographic films, ultrasound, or abdominal CT scans. Gas confined to the collecting system may be seen in a more benign condition, emphysematous pyelitis, most often in association with urinary tract obstruction [ 1 I]. Air can also be introduced into the urinary tract by surgery, trauma, or a fistula communicating with the intestines. Management includes aggressive resuscitation, control of diabetes, and broad-spectrum antibiotics, followed in the majority of cases by nephrectomy. The prognosis of this entity depends on early recognition of the condition, treatment, and type of management (whether surgical, medical, or combined). The overall mortality is 38 per-
bacteria to produce carbon dioxide and hydrogen by fermentation. In the five cases now reported, E. coli was recovered from the primary source, blood, and vitreous aspirate in all the cases. All five cases had underlying diabetes mellitus. The primary source was pyelonephritis in four patients and gangrenous toe in the remaining case. Four of the cases had complete loss of vision in the affected eyes and one had marked diminution of vision (Table I). Clinically, patients with endogenous endophthalmitis usually complain of ocular pain and decreased vision. Other symptoms (as a result of the septicemia) include malaise, fever, and headache. Ophthalmologic findings include conjunctival edema and injection, hazy cornea, hypopyon, and upper lid edema. Because endogenous eye infection can be rapidly devastating with loss of vision, suspected cases should have immediate vitreous aspiration for culture and Gram stain. Both parenteral and intravitreous antibiotics should be administered [5] and subconjunctival or sub-Tenon’s injections and fortified topical antibiotics are commonly used. Vitrectomy has also been recommended to evacuate vitreal abscess and prevent the need for enucleation. Despite advances in antimicrobial therapy, the prognosis fOt’ restoration of vision is poor in gram-negative bacterial endophthalmitis. Endogenous bacterial endophthalmitis should be suspected as a complication of all cases of septicemia with the occurrence of clouding of vision and ocular pain, particularly in elderly patients with underlying diabetes. It is also important to know that, rarely, endophthalmitis could be the initial manifestation of septicemia. A search for the primary site of infection and early treatment with antibiotics may improve the prognosis of this rare complication of septicemia. Gram-negative endophthalmitis is associated with an extremely poor prognosis compared with gram-positive endophthalmitis, which has a relatively good prognosis [6]. For this reason, the recognition of intraocular gas is important, as this clue indicates a form of endophthalmitis requiring very aggressive management. Radiographic examination of the eye in septic patients with clinical evidence of endophthalmitis may be a useful tool in detecting coliform infection if gas is
636
Site
64
ENDOPHTHALMITIS
cent, with only a 29 percent survival rate for those treated medically, compared with a 71 percent rate for those given both medical and surgical treatment. Gram-negative bacterial endocarditis is a very rare disease and narcotic addicts, prosthetic valve recipients, and patients with cirrhosis are at increased risk for this condition. Congestive heart failure is common and the prognosis is poor, with mortality rates of 75 to 83 percent [ 121. The patient currently described had none of the increased risk factors for gram-negative bacterial endocarditis and survived despite the other major complications and underlying diabetes mellitus. In early reports, Salmonella species were the most common Enterobacteriaceae causing endocarditis but, of the other species, E. coli was the leading cause of endocarditis in a review of 44 cases [ 131. In some cities, P. aeruginosa and Serratia marcescens are the major pathogens causing endocarditis in narcotic addicts.
PYELONEPHRITIS-FARAAWI
and
FONG
REFERENCES 1, 2. 3.
4. 5.
6. 7. 8.
9. 10.
CONCLUSION This case is unique in having both emphysematous pyelonephritis and endophthalmitis. Most likely, the mechanism of gas production was the same. Early diagnosis and management are important in both conditions. Likewise, both might require combined surgical and medical treatment.
AND
11, 12.
13.
March 1988
Zakka K, Hirose T: Bilateral endogenous E. coli endophthalmitis. Ann Ophthalmol 1985; 17: 212-215. Cohen P, Kirshner J, Whiting G: Bilateral endogenous E. coli endophthalmitis. Arch Intern Med 1980; 140: 1088-1089. Fanning WL, Stubbert J, Irwin ES, Aronson MD: A case of bilateral E. coli endophthalmitis. Am J Med 1976; 61: 295-297. Shammas HF: Endogenous E. coli endophthalmitis. Surv Ophthalmol 1977; 21: 429-435. Graham RO, Peyman GA, Fishman G: lntravitreal injection of cephaloridine in the treatment of endophthalmitis. Arch Ophthalmol 1975; 93: 56-61. Mandelbaum S, Foster RK: Postoperative endophthalmitis. Int Ophthalmol Clin 1987; 27: 95-106. Klein FA, Smith MJV, Vick CW Ill, Schneider V: Emphysematous pyelonephritis. South Med J 1986; 79: 41-46. Clifford NJ, Katz I: Subcutaneous emphysema complicating renal infection by gas-forming coliform bacteria. N Engl J Med 1962; 266: 437-439. Ireland GW, Javadpour N, Cass AS: Renal emphysema and retention of renal function. J Urol 1971; 106: 463-466. Michaeli J. Moale P. Perlbera S. Heimaw S. Caine M: Emohvsematous pie1onephritis.J Ural 1984; i31: 203-208. . Evanoff GV, Thompson CS, Foley R, Weinman EJ: Spectrum of gas within the kidney. Am J Med 1987; 83: 149-154. Schield WM, Sande MA: Endocarditis and intravascular infections. In: Mandell GC, Douglas JR, Bennett JE, eds. Principles and practice of infectious disease. New York: John Wiley and Sons, 1979; 667-668. Carruthers M: Endocarditis due to enteric bacilli other than Salmonellae. Am J Med 1973; 55: 811-818.
The American
Journal
of Medicine
Volume
84
639