Endogenous Klebsiella pneumoniae panophthalmitis with perinephric and psoas abscesses in a 42-year-old female: case in images
SPMC J Health Care Serv. 2020;6(1):8 ARK: http://n2t.net/ark:/76951/jhcs39brs9
1Department of Ophthalmology, Southern Philippines Medical Center, JP Laurel Ave, Davao City, Philippines
Correspondence Charmaine Grace P Malabanan-Cabebe, email@example.com
Received 2 March 2020
Accepted 29 June 2020
Cite as Malabanan-Cabebe CGP, Villano MAF. Endogenous Klebsiella pneumoniae panophthalmitis with perinephric and psoas abscesses in a 42-year-old female: case in images. SPMC J Health Care Serv. 2020;6(1):8. http://n2t.net/ark:/76951/jhcs39brs9
Endophthalmitis is the inflammation of the intraocular cavities, and panophthalmitis is its most severe form.1 2 3
In panophthalmitis, there is a marked inflammation of the surrounding orbital structures, manifested by severe eyelid edema, proptosis, chemosis and eye movement limitations.4
If left untreated, endophthalmitis could lead to irreversible vision loss and systemic complications.2 4 5
The etiology of endophthalmitis may either be exogenous, by direct inoculation, or endogenous, via hematogenous spread of infectious agents from a distant source.4 6 7
Occurring less commonly than its exogenous counterpart, endogenous endophthalmitis (EE) accounts for only 2 to 15% of all endophthalmitis cases.1 6 7
Gram-negative rods, such Klebsiella pneumoniae are responsible for most of the cases of EE in Asian countries.8 9 10
The most common symptom of endophthalmitis is decreased visual acuity and hypopyon, or pus in the anterior chamber.6 4 11
The diagnosis of endophthalmitis is established through characteristic B-scan ultrasonographic findings such as increased echogenicity of the vitreous, retinochoroidal layer thickening, and retinal detachments.12 13
Other diagnostic procedures that are commonly done are vitreous fluid biopsy, blood culture (which is positive in only a third of cases) and neuroimaging (to evaluate the presence of intraocular foreign body, or sources of intraorbital or intraocular infection).14 15 16
Treatment should be started upon suspicion of endophthalmitis. Treatment usually includes the administration of intravitreal and intravenous systemic antibiotics.14 7
Pars plana vitrectomy is used to treat moderate vitritis.14
It is usually done on patients in the early course of infection, when there is still low virulence of the infective organism.18
Endophthalmitis caused by a gram-negative organism tends to have poor visual acuity outcomes.2
In extreme cases of endophthalmitis, enucleation or evisceration may have to be performed as the last option to control the progress of infection.3
A 42-year-old female complaining of right-eye swelling was admitted under our service. Forty days prior to admission, the patient had fever and chills associated with left flank pain, cloudy urine and bilateral leg edema. About a week after the onset of symptoms, she was admitted for a complicated urinary tract infection (UTI) secondary to nephrolithiasis, given intravenous ceftriaxone, and eventually discharged after ten days, with resolution of symptoms, except for the persistence of minimal left flank pain.
The swelling in the patient’s right eye started five days prior to admission and was associated with eye pain. Four days prior to admission, the patient consulted a physician and was prescribed with unrecalled antibiotic eye drops. Two days prior to admission, when the eyedrops did not afford any relief of the symptoms, the patient consulted a second physician who prescribed acetazolamide 250 mg tablet, one tablet twice a day and levofloxacin 0.5% eye drops, one drop every four hours on the right eye. However, the condition of the patient's right eye did not improve the next day, despite the new medications. She went back to the second doctor, who then made a diagnosis of panophthalmitis and referred her to our institution for further management.
The patient has been diagnosed to have a poorly-controlled diabetes mellitus type 2 for a year now, and she has been poorly compliant with her insulin treatment. The patient denied any recent history of dysuria, hematuria, abdominal pain or changes in bowel movement.
On initial examination, we noted a hyperemic sclera and discharges on the patient’s right eye. Visual acuity test revealed that she had no light perception on the right eye but had 20/20 vision on the left eye. The examination also revealed a grossly edematous, erythematous, and proptotic right eye with severely restricted extraocular movements (Figure 1).
Slit lamp biomicroscopy showed severe diffuse conjunctival injection with perilimbal thickening, mucoid discharge, diffuse corneal edema, and profuse fibrin formation in the anterior chamber (Figure 2). There was no view of the posterior pole due to the fibrin formation and corneal edema. Intraocular pressure was elevated to 42 mmHg on applanation tonometry. Ophthalmic ultrasonography revealed homogeneous hyperechoic dots of low- to mid-reflectivity, with good after-movement. The choroid was thickened (Figure 3).
We admitted the patient with a working diagnosis of endophthalmitis. We then performed a vitreous tap, collected a sample of vitreous fluid for culture, and injected 0.1 ml vancomycin with 1 mg/0.1 mL preparation and 0.1 ml ceftazidime with 2.25 mg/0.1 mL preparation. We also collected blood and urine samples for culture before we started the patient on intravenous ceftriaxone 2 g per day and oral acetazolamide 250 mg twice a day. We also continued giving the patient topical levofloxacin 0.5% eye drops, one drop every four hours on the right eye. On the fourth hospital day, the combination of topical and intravenous antibiotics, and acetazolamide offered partial relief of the eye pain but did not improve the conjunctival injection and mucoid discharge.We opted not to do a pars plana vitrectomy due to the fulminant course of the disease. We opened the possibility of enucleation to the patient, depending on the progress of the infection, however the patient was not open to the procedure.
On the fifth day of admission, results of the vitreous fluid culture done on the day of admission showed growth of Klebsiella pneumoniae. There was no growth in the blood culture, but the urine culture also displayed growth of Klebsiella pneumoniae and Staphylococcus. We then started the patient on intravenous gentamicin 80 mg twice a day and continued the medications that we started on the first day.
Given a diabetic patient with a history of complicated UTI a month prior to admission, with minimal flank pain despite antibiotic treatment, and with urine culture findings of Klebsiella pneumoniae during the present admission, we suspected that the patient had persistent renal infection. This underlying infection could also be a possible endogenous source of the patient’s ongoing endophthalmitis.
Therefore, we requested an ultrasound of the whole abdomen, which revealed a left perinephric abscess formation. At this point, we just continued the patient’s ongoing antibiotic treatment. By this time, we were already considering that the etiology of the patient’s endophthalmitis was endogenous.
On the 14th hospital day, the patient complained of worsening left flank pain. We did a contrast CT scan of the whole abdomen which revealed bilateral pyelonephritis with left perinephric and left psoas abscesses (Figure 4). Approximately, 135 mL of fluid collection was visualized in the left psoas muscle region. The Interventional Radiology service performed a CT-guided percutaneous drainage using a pigtail catheter to drain the psoas and perinephric abscesses.
One month after admission, the patient’s eye became phthisical. After five weeks of antibiotic treatment, the pain and swelling on the patient’s right eye resolved, but vision was not restored. A repeat abdominal CT scan done prior to discharge revealed a markedly regressing left psoas and perinephric abscesses (Figure 5). We discharged the patient 41 days after admission. Our final diagnoses for the patient’s conditions were panophthalmitis of the right eye, and resolved perinephric and psoas abscess.
Erythematous, edematous, and proptotic right eye of the patient.
Anterior segment photo showing diffuse conjunctival injection and extensive fibrin formation in the right eye.
B-scan of the right eye, revealing mild- to moderate-amplitude point echoes with choroidal thickening.
Coronal (A) and axial (B) views of contrast CT scan of the whole abdomen, done on the 21st hospital day, showing left perinephric and psoas abscesses.
Anterior segment photo of the right eye showing marked decrease in anterior chamber inflammation with 360o posterior synechiae.
Repeat CT scan on the 40th hospital day showing markedly regressing left psoas and perinephric abscesses.
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