A 69-year old male with a past medical history of diabetes mellitus type II and cryptogenic cirrhosis with esophageal varices presented to the emergency department with one day of acute bilateral vision loss. The patient endorsed burning pain, photophobia and significant discharge from both eyes. He denied fevers, chills or recent trauma. On exam, patient was noted to have significant eye-lid swelling with injected conjunctiva and white mucous discharge bilaterally. The patient refused to participate in an eye exam due to pain. On labs, patient had a mild leukocytosis of 10.7 K/uL, hemoglobin of 8.3 g/dL, INR of 2 and elevated lactic acid of 3.5 mmol/L. The patient was evaluated by ophthalmology and found to have bilateral endophthalmitis. Given the absence of recent instrumentation or trauma to the eyes, endogenous endophthalmitis was diagnosed. The patient was given intra-vitreous vancomycin and ceftazidime after vitreous cultures and admitted for further work-up. Upon presentation to the medical floor, the patient had multiple episodes of hematemesis with hemoglobin drop to 6.7 g/dL. The patient received a blood transfusion and was started on continuous infusions of esomeprazole and octreotide as well as empiric antibiotic therapy with vancomycin and cefepime. The patient underwent endoscopy with banding of several grade-III bleeding varices. After resolution of the gastrointestinal bleed, he underwent an echocardiogram and abdominal imaging with revealed no identifiable infectious source. Blood cultures were negative however vitreous cultures grew Group B Streptococcus, sensitive to ampicillin. The patient did not regain vision in his right eye however recovered full vision in his left eye after a six-week course of ampicillin.
Endopthalmitis is a visually devastating disease, causing inflammation of the internal ocular spaces. It is very rare with an incidence near 0.32%. Endogenous endophthalmitis (EE) is even less common, accounting for 4% of all cases of endophthalmitis. EE usually results from hematogenous spread from a distant septic focus. Risk increases with underlying diabetes mellitus, malignancy, endocarditis or hepatobiliary infection. Patients with EE are treated with broad-spectrum antibiotics while the focus of infection is worked-up. In our case, there was no evidence of other sources of infection, indicating that the EE occurred in isolation.
Endogenous endophthalmitis is a very rare but serious disease process. Empiric antibiotic therapy should be initiated and urgent ophthalmology consultation should be called. Prompt diagnosis and treatment is crucial if vision is to be preserved. Physicians need to have a high level of awareness of this disease.
To cite this abstract:Santiago SC, Jilani O, Khan S, Chernyavsky S. A Rare Case of Bilateral Endophthalmitis. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 776. https://www.shmabstracts.com/abstract/a-rare-case-of-bilateral-endophthalmitis/. Accessed February 16, 2019.