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A complication of intensive care

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A 44-year-old woman with non-insulin-dependent diabetes mellitus presented with severe respiratory distress secondary to a suspected pulmonary embolus. She required immediate intubation, thrombolysis was administered and she was transferred to the Intensive Care Unit for ventilatory and inotropic support. A ventilation perfusion scan confirmed ventilation perfusion mismatch and she was subsequently anticoagulated. She appeared to be making an uneventful recovery until 7 days later when she developed a temperature. An abnormality of her right eye was noted and on ophthalmological review visual acuity was 6/36; funduscopy revealed multiple choroidal lesions.

Questions

1
What is the abnormality seen in the right eye ?
2
What are the possible causes ?
3
What investigations were undertaken to confirm the diagnosis ?
4
How was this condition managed ?

Answers

QUESTION 1

A right eye hypopyon.

QUESTION 2

Bacterial endophthalmitis, whether endogenous or exogenous, may give rise to a hypopyon. Non-infectious causes include Beçhet's syndrome and, on occasions, the HLA B27 arthritides that are associated with anterior uveitis.

QUESTION 3

A fully sensitive Staphylococcus aureuswas grown from blood taken centrally and peripherally and from a central line tip which had been inserted 5 days previously. As pathogens found in blood cultures and ocular fluid occur with equal frequency, no intravitreal specimen was obtained, although sampling the anterior chamber and vitreous is of importance when the diagnosis is in doubt.1

QUESTION 4

The patient was treated for 6 weeks with flucloxacillin, initially intravenously then orally, and oral fusidic acid, and her hypopyon and choroidal lesions resolved. When last seen the patient was clinically well and visual acuity in her right eye was normal. Treatment with high-dose intravenous therapy is generally sufficient as the passage of organisms is thought to disrupt the blood–ocular barrier, although in severe cases intravitreal antibiotics and vitrectomy are advocated.2 3 As the condition is uncommon there are no controlled data suggesting that either intravitreal antibiotics or vitrectomy is better than more conservative treatment.

Discussion

Bacterial endophthalmitis is a rare but severe sight-threatening form of ocular infection. Exogenous endophthalmitis following ocular surgery or trauma is more common than metastatic blood-borne infection (endogenous endophthalmitis). If left untreated, progressive reduction in vision and ultimately blindness will occur. In recent years the most common organisms causing metastatic endophthalmitis have become Gram-positive bacteria, replacing Neisseria meningitidis, the incidence of which decreased in the 1940s with the introduction of antibiotics. Certain organisms have a clear predilection for particular parts of the eye, withS aureus commonly originating in the posterior segment. It is, on occasions, associated with a reactive hypopyon (figure). With early systemic intravenous treatment, as in this case, focal posterior involvement has a good prognosis. This is in marked contrast to diffuse posterior involvement and panophthalmitis.4 Similar cases, though community acquired, have been reported in diabetics,5 dialysis patients,6 and in patients with lymphoma7who, because of recurrent breaks in the skin, intravenous access and immunocompromised states, are more prone to staphylococcal bacteraemia. In addition to these predisposing factors concurrent non-ocular infection such as urinary tract infections,8 endocarditis and osteomyelitis, should be considered and may not present until after the onset of ocular infection.

In any patient with staphylococcal bacteraemia, metastatic infection of heart valves, joints and bones are well documented. Rarely, the posterior chamber of the eye may become infected and a hypopyon and choroidal lesions should not be overlooked.

Final diagnosis

Nosocomially acquired right eye endophthalmitis caused by aStaphylococcus aureus bacteraemia secondary to an infected central line.

References

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