19 October 2022: Articles
Unusual clinical course, Challenging differential diagnosis, Unusual setting of medical care, Rare disease, Rare coexistence of disease or pathologyFilippo Confalonieri123ACDEF*, Boža Gorenjak de Souza4B, Goran Petrovski125ADEF, Xhevat Lumi24ACDEFG
Am J Case Rep 2022; 23:e937512
BACKGROUND: We report a rare case of unilateral Klebsiella pneumoniae endogenous endophthalmitis with retinal necrosis secondary to acute prostatitis and its clinical management.
CASE REPORT: A 72-year-old immunocompetent male presented with high fever and gastrointestinal and genitourinary symptoms. He was diagnosed with acute prostatitis, hospitalized, and started on a systemic antibiotic. After 3 days, he experienced floaters in the right eye with subsequent loss of vision. He was referred to the ophthalmology department, where endophthalmitis was diagnosed. The patient underwent complete pars plana vitrectomy (PPV); vitreous samples were taken, and intravitreal antibiotics were injected. Intraoperatively, the retina appeared moderately ischemic, with signs of vasculitis and an area of infiltrated retina temporal to the central fovea. The microbiology results from the vitreous samples showed Klebsiella pneumoniae presence. After 9 days, rhegmatogenous retinal detachment ensued and the patient underwent phacoemulsification + intraocular lens implantation in the capsular bag, a second PPV, and silicone oil tamponade. Temporal to the fovea, a large area of retinal necrosis was observed. After a 10-month followup period, the silicone oil was removed, and subsequently, visual acuity improved, while the retina remained attached.
CONCLUSIONS: Klebsiella pneumoniae can be an aggressive microorganism that can cause retinal necrosis and compromise visual function. Prompt PPV can lead to some preservation of vision. This case demonstrates that a second PPV can prove to be a good therapeutic solution and should not be delayed.
Keywords: Endophthalmitis, Klebsiella pneumoniae, Ophthalmology, Prostatitis, Retina, Male, Humans, Aged, Silicone Oils, Anti-Bacterial Agents, Necrosis
Endophthalmitis is an uncommon but potentially sight-threatening condition characterized by inflammation of intraocular tissues and fluids caused by microorganisms . According to the etiology or the way microorganisms are transmitted, this ocular pathology can be divided into 2 categories: exogenous and endogenous . Exogenous endophthalmitis is caused by microorganisms accessing the ocular tissues through the external environment; most commonly, it occurs as a complication of ocular surgery, trauma, or intravitreal injections . Endogenous endophthalmitis (EE) occurs through hematogenous spread of microorganisms from inflammatory lesions elsewhere in the body. EE occurs when pathogenic microorganisms enter the bloodstream, and, via a damaged blood-ocular barrier, enter the retina and the vitreous . Both categories lead to intraocular inflammation and potentially severe visual loss . Only 53% of patients with EE are initially examined by an ophthalmologist; 35% present to an internist, general practitioner, pediatrician, or emergency department physician . Therefore, collaboration among members of a diverse medical team, including experts in intensive care and infectious diseases, is frequently required. There are no recommendations for treating EE since it is relatively rare . Several microorganisms have been known to cause bacterial EE, such as
Retinal necrosis is a consequence of severe chorioretinitis and can be caused by multiple diseases, including acute retinal necrosis caused by varicella zoster virus (VZV) or herpes simplex virus (HSV-1 or HSV-2). Retinal necrosis can also be caused by cytomegalovirus chorioretinitis, toxoplasma chorioretinitis, and endophthalmitis . Here, we report a rare case of EE with retinal necrosis caused by
A 72-year-old immunocompetent male presented with severe high fever and gastrointestinal and genitourinary symptoms. At the urology department, he was diagnosed with acute prostatitis, hospitalized, and started on systemic antibiotic therapy. He received gentamycin 240 mg per 24 h i.v. empirically. From urine culture collected on admission, ampicillin-resistant
EE is a relatively rare but potentially devastating condition, accounting for only 2 to 16% of all endophthalmitis cases. The literature on EE mostly comprises case series or single case reports [6,20–22]. Due to the paucity of EE cases, unlike exogenous endophthalmitis, demographics, treatment options, and outcome measures in patients with EE have not been evaluated in large-scale studies .
Risk factors like diabetes and conditions associated with immunosuppression may play a major role in the development of EE secondary to
When bacterial endophthalmitis occurs, in the acute phase, microorganisms induce an inflammatory response that damages the retinal cells. Inflammation of the arterioles leads to occlusive events, favoring rapid necrosis of the retinal tissue . In the late phase, contractile membranes may form on the surface of the retina. Both retinal necrosis and membrane proliferation can produce multiple retinal breaks and defects that may lead to retinal detachment [31,32]. A similar process occurs in acute retinal necrosis, in which retinal detachment has been described in up to 75% of eyes within 3 months of the onset of symptoms [33,34].
EE due to
A devastating outcome in a case of EE due to
Recent literature has reported an increase in the incidence of
The emergence of carbapenem-resistant
In our scenario, the infection took 3 days to spread from the prostate to the eye. This is most likely because seeding through the bloodstream requires at least a few hours to take place. This period should alert the clinician to the clinical suspicion of endophthalmitis in the very first few days after the diagnosis of the primary infection, especially given the prevalence of multidrug-resistant bacteria. As indicated in our example, performing an early complete vitrectomy is critical for the functional prognosis in these patients.
Hereby, we report a rare case of
EE is an intraocular inflammation with possible serious consequences for vision.
FiguresFigure 1.. Postoperative right eye showing silicone oil in the vitreous cavity, flat retina, and an extensive necrotic retinal area temporal to the macula (arrow). Figure 2.. Ten-month postoperative optical coherence tomography scan passing through the fovea showing the atrophic retina (arrow). Figure 3.. Ten-month postoperative fundus image showing flat retina with an extensive, stable, temporal area of necrotic retina (arrow). Video 1.. Endophthalmitis with retinal necrosis.
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