A Case of Klebsiella pneumoniae associated Endogenous

Endophthalmitis in a patient with Diabetes Mellitus Type 2 and Pyogenic Hepatic Abscess

Jan Patrick O. Chu, MD, Egidio S. Fortuna, MDDepartment of Ophthalmology

Quirino Memorial Medical CenterQuezon City, Philippines

Endogenous endopthalmitis is an intraocular infection that is not related to an

external source like surgery and trauma. Patients present with severe blurring of

vision, eye pain, eye redness, photophobia, and periorbital or eyelid edema. It is

associated with clinical co-morbidities and has visual-threatening complications.

Background:

To present a case of Endogenous Endophthalmitis associated with Klebsiella pneumoniae bacteremia and pyogenic liver abscess in a patient with Diabetes Mellitus type 2

Objective:

12/11/16

• VA OS: CF@3 ft• Hyperemic conjunctiva• Clear Cornea• Deep anterior chamber• Pupil reactive to light • Clear vitreous• Pale and elevated

inferotemporal retina with flame shaped haemorrhages

Impression: • Acute Viral

Conjunctivitis, OS• Retinal Detachment,

OS

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

12/19/16

• VA OS: HM • Axial proptosis• Periorbital eyelid tenderness and

swelling• Matting of lashes • Mucopurulent discharge• Hyperemic conjunctiva • Conjunctival chemosis• Ciliary injection• Hazy cornea• Anterior chamber plasmosis• +4 cells and flare• Grade 1 hypopyon• Pupillary hypopyon• Pupil non-reactive to light• IOP OS: 30mmHg • Ophthalmoplegia

B-scan ultrasonography: Vitritis, posterior vitreous

detachment, attached retina and posterior scleritis

Impression : Panuveitis, OS

Case

ManagementOn admission, patient also presented with:

• Fever (39.4 C)• Chills

Medications:

Topical medications: (left eye)• Moxifloxacin eye drops • Atropine sulfate eye drops • Prednisolone acetate eye drops • Brimonidine + Timolol eye drops

Systemic medications: • Ceftriaxone 1g IV• Paracetamol 300mg IV• Acetazolamide 250mg

• Irregular hyperechoic foci with no internal vascularity on color Doppler Study involving the right lobe of the liver predominantly segments V and VI abutting the undersurface of the right portal vein measuring 91.2 x75.5 x 107.8mm (388.4cc)

• A smaller focus in segment V adjacent to the gallbladder fossa measuring 17 x 11.4 x 22.2mm (2.24cc)

Liver Ultrasound

Normal liver parenchyma Liver abscess

Kidney

• Well defined, lobulated rim enhancing hypodense lesion of fluid density, measuring 6.0 x 8.3 x 6.5 cm (AP x T x CC) is noted involving the inferior segments of the right hepatic lobe (segment V and VI)

• A 1.4 x 1.8cm enhancing hypodense nodule is also seen in the infero-anterior segment of the liver

Triphasic Whole Abdominal CT Scan

Cranial CT Scan with Orbital Cuts and IV Contrast

• Diffuse thickening of the left globe associated with preseptal–periorbital soft tissue swelling

• Minimal retrobulbar fat stranding, enlargement of the lacrimal gland, proptosis, and subtle enlargement of extraocular muscles

Management

Management

12/24/2016

VA OS: NLPEye Pain

Enucleation, OS done

• AP diameter – 3.0cm• Horizontal diameter 2.5cm• Vertical diameter 1.8cm• Optic nerve 0.7cm

•Purulent material occupying the vitreous chamber with anteriorly displaced lens

Selected Organism:Klebsiella pneumoniae

Card: AST-N261 Lot Number 6810133403 Expires: 2018-04-08

Susceptibility Information Completed: 2016 Status; Final Analysis Time: 09.15.00 hoursAntimicrobial MIC Interpretatio

nAntimicrobial MIC Interpretatio

nESBL Neg - Imipenem <=0.25 S

Cefepime <=1 S Ampicillin >=32 R

Ertapenem <=0.5 S Amoxicillin/Clavulinic Acid <=2 S

Piperacillin/Tazobactam <=4 S Meropenem <=0.25 S

Cefuroxime 2 S Amikacin <=2 S

Gentamicin <=1 S Cefoxitin <=4 S

Ciprofloxacin <=0.25 S Ceftriaxione <=1 S

Trimethoprim/Sulfamethozazole <=20 S

Added Metronidazole 500mg TIV BID

Histopathology Report

Fibrinoid necrosis and masses of red blood cells and inflammatory aggregates composed predominantly of neutrophils and some

lymphocytes

Polymorpho-nuclear cells

predominantly neutrophils

Mononuclear cell infiltration of the choroid

layer

Congested blood vessels

DiscussionEndogenous Endophthalmitis is a rare condition. It represents only 2-8% of all endophthalmitis cases. 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

pneumoniae 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.

PRIMARY SITE OF INFECTION

Posterior segment vasculature of the

eye

Direct spread via optic nerve

Septic Embolus

Crosses Blood Ocular Barrier

Microbial Proliferation

& Inflammatory

Reactions

Conclusion

Endogenous endophthalmitis is a rare condition that has poor visual outcome despite

aggressive treatment. It can initially be misdiagnosed, which affects disease outcome due

to delay in proper management. Klebsiella pneumoniae-associated 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

condition. This is the first report of such case from our institution.

References1. Ang, M., Jap, A., & Chee, S. P. (2011). Prognostic factors and outcomes in endogenous Klebsiella pneumoniae

endophthalmitis. American Journal of Ophthalmology, 151(2), 338-344.

2. Connell, P. P., O'neill, E. C., Fabinyi, D., Islam, F. M. A., Buttery, R., McCombe, M., ... & Campbell, W. (2011).

Endogenous endophthalmitis: 10-year experience at a tertiary referral centre. Eye, 25(1), 66.

3. Hu, C. C., Ho, J. D., Lou, H. Y., Keller, J. J., & Lin, H. C. (2012). A one-year follow-up study on the incidence and

risk of endophthalmitis after pyogenic liver abscess. Ophthalmology, 119(11), 2358-2363.

4. Sadiq, M. A., Hassan, M., Agarwal, A., Sarwar, S., Toufeeq, S., Soliman, M. K., ... & Nguyen, Q. D. (2015).

Endogenous endophthalmitis: diagnosis, management, and prognosis. Journal of ophthalmic inflammation and

infection, 5(1), 32.

5. Vaziri, K., Pershing, S., Albini, T. A., Moshfeghi, D. M., & Moshfeghi, A. A. (2015). Risk factors predictive of

endogenous endophthalmitis among hospitalized patients with hematogenous infections in the United States.

American journal of ophthalmology, 159(3), 498-504.

6. Yang, Chang-Sue, Hsien-Yang Tsai, Chun-Sung Sung, Keng-Hung Lin, Fenq-Lih Lee, and Wen-Ming Hsu.

"Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess." Ophthalmology 114, no. 5 (2007):

876-880.