Bilateral endogenous endophthalmitis secondary to endocarditis with negative transesophageal echocardiogram

Systematic review of 342 cases of endogenous bacterial endophthalmitis

We review a total of 342 cases of endogenous bacterial endophthalmitis reported between 1986 and 2012. Predisposing conditions were present in 60%, most commonly diabetes, intravenous drug use, and malignancy. The most common sources of infection were liver, lung, endocardium, urinary tract, and meninges. Systemic features such as fever were present in 74%, hypopyon in 35%, and an absent fundal view in 40%. Diagnostic delay occurred in 26%. Blood cultures were positive in 56%, and at least one intraocular sample was positive in 58% (comprising 26% anterior chamber samples, 59% vitreous taps, and 41% vitrectomy specimens). Worldwide, Gram negative infections (55%) were more frequent than Gram positive (45%) infections, particularly in Asia. Over the last decade, 11% of eyes were treated with systemic antibiotics alone, 10% intravitreal antibiotics alone, 36% systemic plus intravitreal antibiotics, and 20% systemic plus intravitreal antibiotics plus pars plana vitrectomy. The most commonly used intravitreal antibiotics were vancomycin (for Gram positive infection) and ceftazidime (Gram negative). The median final visual acuity was 20/100, with 44% worse than 20/200. Among all cases, 24% required evisceration or enucleation, and mortality was 4%. Both intravitreal dexamethasone and vitrectomy were each associated with a significantly greater chance of retaining 20/200 or better and significantly fewer eviscerations or enucleations-these warrant further study. For most patients, treatment should include a thorough systemic evaluation and prompt intravitreal and systemic antibiotics.

Uveitis associated with septic peritonitis in a cat

OBJECTIVE

To report a case of bilateral uveitis believed to be a consequence of septic peritonitis in a 19-month-old cat.

CASE SUMMARY

Bilateral anterior uveitis with suspicion of extension to the posterior segment was documented in a previously healthy young cat during hospitalization for severe septic peritonitis. Based on medical history and other findings uveitis was believed to result from concurrent abdominal sepsis, due either to metastatic seeding of bacterial organisms or to effects of bacterial toxins and inflammatory mediators on the blood-aqueous barrier. The cat was surgically and medically managed, and made a full recovery with respect to both his ocular and his abdominal disease.

NEW OR UNIQUE INFORMATION PROVIDED

Ocular complications secondary to systemic sepsis are well documented in people but seldom reported in the veterinary literature. To the authors' knowledge this is the first report of uveitis linked to septic peritonitis in any veterinary species and the first to report sepsis-related uveitis in a cat. Ocular inflammatory disease in the context of critical illness deserves attention as a potential significant source of morbidity. The development of ocular inflammatory disease may serve as a sentinel lesion for systemic sepsis and other life-threatening conditions.

Endogenous fungal endophthalmitis after cardiac surgery

The authors present a single-patient interventional case report of endogenous fungal endophthalmitis (EFE) in a patient with an implanted prosthetic device. A 74-year-old man underwent a double coronary artery bypass graft with a bioprosthetic pericardial valve and transvenous dual chamber pacemaker. Four months later, he presented with EFE. Despite aggressive local and systemic antifungal therapy, the patient died of septic shock due to a fungally infected pacemaker. Successful management of post-cardiac surgery EFE requires aggressive local and systemic antifungal therapy, but without surgical removal of implanted thoracic hardware these modalities alone may be insufficient for a cure.

High prevalence of fastidious bacteria in 1520 cases of uveitis of unknown etiology

The etiologic evaluation of uveitis is frequently unsuccessful when noninvasive methods are used. We conducted a prospective study to evaluate systematic screening for pathogens of uveitis. All patients with uveitis referred to the participating tertiary ophthalmology departments from January 2001 to September 2007 underwent intraocular and serum specimen collection. The standardized protocol for laboratory investigations included universal polymerase chain reaction (PCR)-based detection of any bacteria and mycoses, specific PCR-based detection of fastidious (difficult-to-grow) bacteria and herpes viruses, and culture of vitreous fluid. Sera were tested for fastidious bacteria. Among the 1321 included patients (1520 specimens), infection was diagnosed in 147 (11.1%) patients: 78 (53%) were caused by fastidious bacteria that included spirochetes, Bartonella species, intracellular bacteria (Chlamydia species, Rickettsia species, Coxiella burnetii), and Tropheryma whipplei; 18 by herpes viruses; and 9 by fungi. Bartonella quintana, Coxiella burnetii, Paracoccus yeei, Aspergillus oryzae, and Cryptococcus albidus were found to be associated with uveitis for the first time, to our knowledge. We recommend applying a 1-step diagnostic procedure that incorporates intraocular, specific microbial PCR with serum analyses in tertiary centers to determine the etiology of uveitis.