Title : Unilateral endophthalmitis caused by streptococcus pneuemonia
Abstract:
Introduction
Endophthalmitis is a rare infection of the interior eye by bacteria or fungi. These infections are usually exogenous and are caused as a complication of ophthalmic procedures or penetrating ocular trauma(1) Endogenous endophthalmitis is a rare condition that carries a high risk of vision loss. Risk factors for developing endogenous endophthalmitis include having a systemic source of infection and one or more risk factors for immunosuppression. (2) We present a case of a 62 year old female with recent cardiac surgery who presented with altered mental status and fevers, patient grew blood cultures positive for streptococcus pneumonia and subsequently developed right endogenous endophalthimitis
Case report
A 62 year old female with a past medical history of hepatitis c (treated), severe aortic stenosis s/p bio prosthetic valve replacement 8 weeks prior to admission with altered mental status, fever, and back pain.
Vitals revealed temperature 99.4, heart rate 88bpm, blood pressure 128/71, respiratory rate 20 breaths per minute, oxygen saturation is 98%.labs revealed lactate 2.79, and blood culture reveals gram positive bacteremia which turn out to be streptococcus pneumonia. She was started on ceftriaxone 2gram bid.
Patient started to complain of headaches with floaters in right eye, tte and tee was done which was negative for vegetation. Mri of the brain also revealed t2 hyperintensity and diffusion restriction associated with the bilateral occipital horns without associated susceptibility artifact or ependymal enhancement. Findings were concerning for ventriculitis.
Patient had worsening symptom of pain and loss of vision in od>>>os, floaters. Ophthalmology was consulted and their examination revealed photosensitive eomi, marked edema od>>os, injected conjunctiva with copious drainage bilaterally with poor view of the fundus od>>os due to vitritis
The next day, patient began to see black spheres with poor visual acuity on the right and left. His final visual acuity was no light perception in the right eye and 20/50 in the left eye. Patient was transferred to special eye center for further evaluation and intravitreal antibiotics.
Discussion
Our patient's medical sequelae demonstrate the importance of early detection of ee as an indicator of severe, potentially devastating systemic disease. Despite the increasing volume of research, challenges remain in the diagnosis and treatment of bacterial ee. Previous retrospective studies show that incorrect diagnosis of ee occurs in up to 50% of cases
Endogenous endophthalmitis comprises approximately 2 to 8% of endophthalmitis cases(3)streptococcus pneumoniae is only found in 0% to 5% of all ee cases,bacterial ee is usually unilateral with bilateral disease occurring in just 12 to 14% of patients.ee is associated with systemic risk factors, such as recent surgery, urinary tract infections, endocarditis, gastrointestinal tract infections, immunosuppressive diseases and therapies, and chronic immune-compromising illnesses(4) endogenous endopthalmitis is an ophthalmologic emergency with high morbidity and poor visual outcomes. Endogenous endophthalmitis occurs by hematogenous spread of a microorganism from one site in the body to another. Microorganisms more commonly affect the right eye because of the more direct hematogenous spread through the right carotid artery. Within bacterial ee, staphylococcus aureus is the most common organism in the developing world.
Gram-negative species are known to be more common in the asian population. Streptococcus pneumoniae is only found in 0% to 5% of all ee cases.bacterial ee is usually unilateral, with bilateral disease occurring in just 12% to 14% of patients.endogenous endophthalmitis is associated with systemic risk factors, such as recent surgery, urinary tract infections, endocarditis, gastrointestinal tract infections, immunosuppressive diseases and therapies, and chronic immune-compromising illnesses.
5 the prognosis of ee is poor, frequently resulting in complete vision loss. Streptococcal endophthalmitis carries a particularly poor prognosis, as approximately 40% of patients have no remaining vision, and 25% of patients require enucleation or evisceration.4 currently, there are no established guidelines regarding management of ee. As first-line treatment, most experts recommend performing a vitreous tap followed by injection of intravitreous antibiotics (“tap and inject”).6 The prognosis of ee is worse than in other types of endophthalmitis. In a retrospective study on all-cause endophthalmitis, ee was an independent risk factor for evisceration or enucleation.7
The predisposing factors are [1,2]diabetes mellitus, use of intravenous drugs, recent surgery, valvular cardiac diseases, renal insufficiency, neoplasias, corticosteroid therapy, and immunosuppressive therapy. The right eye is generally more affected than the left eye, which is probably due to direct blood flow from the heart [4].
The most common causes of endogenous endophthalmitis are meningitis, endocarditis, urinary tract infection and wound infection [5]. Other sources of infection have included pharyngitis, pneumonia, septic arthritis, pyelonephritis, intra-abdominal abscess and gastrointestinal malignancy. About 25% of the cases are bilateral and usually caused by [5] meningococcus, escherichia coli and klebsiella sp
Conclusion
Diagnosing endogenous endophthalmitis early is essential to initiating a systemic evaluation for potentially life-threatening medical conditions, including sepsis, endocarditis, and osteomyelitis. A high degree of suspicion, expeditious treatment, and interdisciplinary collaboration are essential to maximizing patient outcomes.
We believe our emergent, collaborative efforts led to saving patient’s left and right eye and ultimately his life. Continued efforts to quickly diagnose and treat patients with ee are essential to maximizing both ophthalmologic and systemic outcomes.
