Klebsiella pneumoniae cryptogenic liver abscess and endophthalmitis – a case report and review of literature

Klebsiella pneumoniae has emerged as the predominant pathogenic agent of liver abscess in Asia, and the incidence is increasing worldwide. Hypervirulent strains are associated with septic metastatic dissemination in the eyes, lungs, and central nervous system, causing severe morbidity. We present the case of a 54year old man, with no previous comorbidities, admitted in emergency for the blind red painful eye. Further investigation documented septic endophthalmitis with transscleral extension and orbital cellulitis. Thoraco-abdominal computed tomography evidenced a hepatic abscess as the locus of the primary infection. Intravenous antibiotherapy with cefuroxime, followed by meropenem and vancomycin were efficient for managing the hepatic abscess. However, as the eyeball was perforated at the admission, evisceration was performed. The vitreous sample revealed Klebsiella pneumoniae, with a positive string test as the etiologic agent. The diagnostic and therapeutic management required a permanent collaboration between an ophthalmologist, infectious diseases specialist, surgeon, and radiologist.

Comparisons of Vitreal Angiogenic, Inflammatory, Profibrotic Cytokines, and Chemokines Profile between Patients with Epiretinal Membrane and Macular Hole

Objectives. Idiopathic epiretinal membrane (iERM) or idiopathic macular hole (iMH) is frequently used as a “healthy” control in comparison of vitreous cytokines with other vitreoretinal diseases. This study aimed to investigate if there is a difference in vitreal cytokines expression between patients with iERM and iMH. Methods. In this prospective study, all subjects received standard pars plana vitrectomy surgery, and 0.5 ml of native vitreous sample was extracted during the vitrectomy. Luminex technology and enzyme-linked immunosorbent assay were used to profile the concentration of 52 classic angiogenic, inflammatory, and profibrotic cytokines and chemokines. Statistical analyses were performed by the Mann–Whitney U test, followed by multiple comparisons by the Bonferroni correction. Results. Vitreal samples from 13 iERM and 24 iMH were studied. Of the 52 tested cytokines, 41 were similar in expression, and 5 were under the detection limit, while 6 cytokines (MMP-8, Eotaxin, MIP-1a, RANTES, TGF-β2, and IL-4) were differently expressed between two groups ( p < 0.05 ). Nevertheless, these significances disappeared after the adjustment of Bonferroni correction. Conclusion. The tested cytokines showed similar expression between iERM and iMH patients. This indicates that eyes with iERM or iMH can be together served as “healthy” controls.

Macular pucker, an atypical clinical presentation of ocular toxoplasmosis: a case report

Background Ocular toxoplasmosis caused by Toxoplasma gondii is an infectious disease which is widely distributed around the world and can present with various clinic manifestations. We are here reporting an unusual case presented with epiretinal membrane (ERM), i.e., macular pucker. Case presentation A 16-year old male patient visited our outpatient clinic complaining of decreased vision for about 8 years in his left eye. The best-corrected visual acuity (BCVA) was 20/20 OD and 20/400 OS. There was sensory exotropia in his left eye. No inflammatory cells or flare were found in his anterior chamber or vitreous cavity OU. An ERM involving his left macular area was found on his dilated fundus exam, which was confirmed by Optical Coherence Tomography (OCT). The ERM was found to involve his left macular area with his foveal ellipsoid zone absent. The right eye was found to be within normal limit. After a thorough discussion with the patient and his parents about treatment options and surgical benefits, risks and alternatives, we performed vitrectomy, peeled off the ERM and collected the vitreous sample for parasite testing during the procedure. Patient’s blood also was drawn for serological testing. Vitreous sample analysis and serological tests confirmed ocular toxoplasmosis OS as his final diagnosis. Unfortunately, the BCVA of this patient was not improved after the surgery, but the exotropia disappeared. Conclusion ERM is an unusual clinical presentation of ocular toxoplasmosis. We may add Toxoplasma gondii infection as a differential diagnosis when encountering ERM cases.

Atypical bilateral acute retinal necrosis in a coronavirus disease 2019 positive immunosuppressed patient

Purpose: To present the clinical features of a rare case of atypical acute retinal necrosis in a Coronavirus Disease 2019 (COVID-19) positive immunosuppressed patient. Methods: Retrospective observational case report. Results: A 75-year-old lady presented with a left eye pan uveitis picture with vitritis and extensive peripheral and mid-peripheral necrotising retinitis. In the right eye, she had a very mild superior peripheral retinitis with minimal anterior or vitreous inflammation. Two months prior to her diagnosis she completed a course of rituximab and chlorambucil chemotherapy for a relapse of diffuse large cell B-cell lymphoma (DLBCL). The patient’s nasopharyngeal swabs tested positive for COVID-19 in a reverse transcription polymerase chain reaction (RT-PCR) assay. The vitreous sample PCR tested positive for Varicella Zoster Virus and was negative for SARS-CoV-2. Conclusion and Significance: To the best of our knowledge this is the first description of a case that has undergone vitreous PCR testing for COVID-19. It is interesting to note the high level of vitreous inflammation which would not be expected in an immunosuppressed state. We present a number of possible links between the SARS-CoV-2 virus and the unusual ocular presentation of bilateral VZV viral retinitis in this patient. While extra ocular VZV outbreaks have been reported with rituximab treated patients, this report should also raise the awareness of VZV related viral retinitis in DLBCL patients on rituximab chemotherapy which is a very rare occurrence. This case may provide some evidence to healthcare policy makers who are making decisions regarding the re-introduction of routine Ophthalmic surgery.

Rapid Pathogen Identification With Direct Application of MALDI-TOF Mass Spectrometry on an Endophthalmitis Vitreous Sample Without Prior Culture

Purpose:We report a case of a 72-year-old man with bleb-related endophthalmitis (BRE) whose vitreous samples were directly analyzed with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) to rapidly identify the causative organism, whereas the results from conventional microbiological techniques were negative.Methods:We analyzed BRE vitreous samples with MALDI-TOF MS (Vitek MS, bioMérieux) for rapid pathogen identification without prior culture. Samples were also analyzed with standard microbiological methods.Results:Within 1 hour of sample acquisition, MALDI-TOF MS identified Gemella sanguinis from the undiluted vitreous sample from vitrectomy without prior culture with a confidence value of 99.7%. Gram stain and cultures from aqueous and vitreous samples were negative for 28 days after acquisition. The patient’s right-eye vision improved from hand motion to 20/50 2 months later.Conclusions:Our findings suggest that the direct analysis of intraocular samples with MALDI-TOF MS could be a novel, promising adjuvant method of rapid endophthalmitis diagnosis.

Endophthalmitis after dropless (Tri-Moxi injection) cataract surgery

Introduction: A case of endophthalmitis after dropless cataract surgery with intravitreal Tri-Moxi associated with severe vision loss. Case summary: An 82-year-old male developed severe vision loss in the left eye 24 days after dropless cataract surgery with intravitreal Tri-Moxi injection. Best corrected visual acuity was hand motion in the left eye. Intraocular pressure was 13, with inferior keratic precipitates, 4 + cell with 1 mm layered hypopyon, and a plaque on the posterior capsule that blocked direct exam of the posterior segment. Ultrasonography revealed extensive vitritis without retinal or choroidal detachments. Conclusion: Endophthalmitis resolved and vision improved after management with vitreous tap, intravitreal and fortified topical antibiotics, and subsequent prompt pars plana vitrectomy. Vitreous sample grew fluoroquinolone-resistant staphylococcus epidermidis.

The blinding bug found in the eye

Tubercular uveitis is a common manifestation of tuberculosis (TB) in TB-endemic countries. Due to lack of gold standard diagnostic tests for confirming intraocular TB, it is often either underdiagnosed or rarely over diagnosed. We report a case of a 28-year-old woman with diminution of vision in the left eye. She was started on antitubercular treatment (ATT) and steroids but she did not comply with the treatment. She developed progressive painful loss of vision consequently and was treated with vitrectomy and silicone oil tamponade. After a complete course of ATT, she recovered, salvaging of eye and restoration of some vision was possible. Mycobacterium tuberculosis is rarely demonstrated in the ocular fluid samples of the suspected cases of TB due to the paucibacillary nature of the disease. A vitreous sample can be obtained from these patients. Surgical intervention in the form of vitrectomy and silicone oil tamponade can help in avoiding enucleation/evisceration.

Identification of Dietzia Species in a Patient with Endophthalmitis following Penetrating Injury with Retained Intraocular Metallic Foreign Body

To the best of our knowledge, we report the first case of Dietzia species in a patient with endophthalmitis. A 47-year-old man presented to the ophthalmology department with decreased vision, redness, and minimal pain in his right eye after a foreign body struck his eye following working using a hammer and chisel. Broad-spectrum polymerase chain reaction (PCR) and deoxyribonucleic acid (DNA) sequencing targeting 16S ribosomal ribonucleic acid-(rRNA-) encoding gene on an undiluted vitreous sample revealed 100% identity with GenBank sequences of Dietzia species including D. natronolimnaea, D. dagingensis, and D. cercidiphylli. The culture of the vitreous samples demonstrated the growth of Gram-positive cocci and polymorphic rods. The isolate from the culture was identified as D. natronolimnaea using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). The combination of surgical and medical treatment (pars plana vitrectomy and systemic and topical antibiotics) eradicated the infection successfully.

Intraocular Lymphoma or Infection? Subretinal Aspirate Confirms the Diagnosis

Purpose. To demonstrate the importance of subretinal biopsy to reach a diagnosis when vitreous biopsy is negative or inconclusive. Methods. A 54-year-old Caucasian gentleman presented with bilateral anterior uveitis at JCUH. He initially responded to topical steroids and dilating agents. Subsequently he developed bilateral panuveitis and cataract with poor response to treatment. Detailed workup had been done to rule out infectious etiology. A suspicion of lymphoma was considered and vitreous biopsy sample was taken from one eye, which was inconclusive. Then, to help with definitive diagnosis vitreous sample, subretinal aspirate and retinal biopsy were taken. Results. Subretinal aspirate revealed Aspergillus niger. Treatment was initiated accordingly. Conclusions. Subretinal aspirate and retinal biopsy can help with diagnosis of unusual clinical panuveitis like presentation.