A Case of Klebsiella Pneumoniae Associated Endogenous Endophthalmitis in a Patient with Diabetes Mellitus Type 2 and Pyogenic Hepatic Abscess


SCIENTIFIC POSTER

A Case of Klebsiella penumoniae associated Endogenous Endophthalmitis in a patient with Diabetes Mellitus Type 2 and Pyogenic Hepatic Abscess by Jan Patrick O. Chu, Philippines


ABSTRACT

Objective:

To present a rare case of Endogenous Endopththalmitis associated with Klebsiella pneumoniae bacteremia and pyogenic liver abscess in a patient with diabetes mellitus type 2. Background: Endogenous endopthalmitis is an intraocular infection that is not related to an external source like surgery and trauma. Patients usually present with severe blurring of vision, eye pain, eye redness, photophobia, and periorbital or eyelid edema. It is associated with a number of clinical co-morbidities and has visual-threatening complications.

Case Summary:

A 35-year-old diabetic male had a two-day history of blurring of vision associated with eye redness, tearing and burning sensation of the left eye. His visual acuity was counting fingers at 3 feet. On examination, the conjunctiva was noted to be hyperemic. Posterior segment examination revealed clear vitreous. There were multiple flame shaped hemorrhages on the inferior arcade and the inferotemporal retina was pale and elevated. The patient was initially managed as a case of viral conjunctivitis and referred to the retina service. On subsequent consults, the visual acuity worsened to hand movement. There was progressive worsening of the anterior segment findings. He developed axial proptosis, periorbital swelling, matting of lashes and mucupurulent discharge. There was marked conjunctival chemosis, corneal haze, anterior chamber plasmosis with +4 cells and flare, grade 1 hypopyon. Intraocular pressure was elevated at 30mmHg and there was ophthalmoplegia. B-scan ultraso nography showed vitritis, posterior vitreous detachment, attached retina and posterior scleritis. He was managed as a case of panuveitis, but due to progression of symptoms, medication was augmented with intravenous Ceftriaxone and Moxifloxacin ophthalmic drops. Cranial CT scan with orbital cuts showed diffuse inflammation of the left intraorbital structures. Triphasic whole abdominal CT scan showed a 6.0 x 8.3 x6.5 cm enhancing hypodense lesion in the right hepatic lobe interpreted as an abscess. Blood culture and sensitivity showed heavy growth of Klebsiella pneumoniae. He was started on intravenous Metronidazole. The patient’s eye condition worsened with deterioration of the visual acuity to no light perception and intractable eye pain. A decision was made to do enucleation. Gross and histopathological examination showed an abscess formation described as yellow-white to tan-red material in the posterior chamber, and fibrinoid necrosis with masses of red blood cells and predomi nantly neutrophilic infiltrates in all chambers of the eye. The aforementioned pathological findings confirm the diagnosis.

Discussion:

Endogenous Endophthalmitis is a rare condition and comprises only 2-8% of all endophthalmitis cases. This condition is caused by hematogenous dissemination from an extraocular focus of infection or direct extension via the optic nerve when the primary focus of infection involves the central nervous system. It may occur as the primary manifestation of an underlying systemic illness. In Asia, the more commonly associated causative organisms are the gram-negative bacteria, especially Klebsiella pneumoniae. It has also been strongly linked to liver abscesses. In cases of Klebsiella related endogenous endophthalmitis associated with a liver abscess, the most common underlying risk factor is diabetes mellitus, especially in the Asian population. Treatment options include systemic intravenous antibiotics, intravtireal antibiotics and posterior vitrectomy. However, visual outcome is still poor despite aggressive treatment.

Conclusion:

Endogenous endophthalmitis is a rare condition that has poor visual outcome despite aggressive treatment. It tends to be initially misdiagnosed, which affects disease outcome due to delay in proper management. Klebsiella-induced endogenous endophthalmitis is highly associated with pyogenic liver abscess in particular patients with diabetes, which is the major underlying co-morbidity. Due to the rarity of this condition, there has not been a structured guideline for optimum management of this ocular conditon. This is the first report of such case from this institution.

References:

Sadiq, A.S., Hassan, M., et al (2015). Endogenous endophthalmitis: diagnosis, management, and prognosis. Journal of Ophthalmic Inflammation and Infection. (2015) 5:32, doi 10.1186/s12348-015-0063-y. Vaziri, K., Pershing, S., etr al (2015).

Risk Factors Predictive of Endogenous Endophthalmitis Among Hospitalized Patients With Hematogenous Infections in the United States. American Journal of Ophthalmology 2015;159:498–504. Chang, S., Tsai, H.T., et al (2007).

Endogenous Klebsiella Endophthalmitis Associated with Pyogenic Liver Abscess. Ophthalmology 2007; 114:876 –880. Chao-Chien, H., Jau-Der, H., et al (2012).

A One-Year Follow-up Study on the incidence and Risk of Endophthalmitis after Pyogenic Liver Abscess). Ophthalmology 2012;119:2358–2363. Ang, M., Jap, A., Soon-Phaik, C., (2011).

Prognostic Factors and Outcomes in Endogenous Klebsiella pneumoniae Endophthalmitis. American Journal of Ophthalmology 2011;151:338–344.


CONTACT DETAILS

 

Jan Patrick Chu
Quezon City, Philippines
Email : janpatrickchu@gmail.com
Cell Phone: +639778268880
Work Phone: +639228567351