CORRESPONDENCE Endogenous bacterial endophthalmitis caused mentioned earlier were normal. A repeat B-scan showed by Pantoea species: a case report significantly increased vitreous opacities (Fig. 1). The Endophthalmitis is a severe intraocular infection that may be classified as exogenous or endogenous.1 Pantoea species are gram-negative bacilli in the Enterobacteriaceae family, which are pathogenic to both plants and humans. We present the first case of Pantoea endogenous endophthalmitis in a systemically healthy patient. A healthy 58-year-old male was referred by his optometrist to our emergency eye clinic with a 1-day history of sudden onset of progressively painful vision loss in the left eye. The patient denied any recent trauma or inciting incident. He had a tick removed from his back 1 month previously but did not have a target lesion. He also had a dental procedure 1 to 2 months before presentation. He denied fever, chills, myalgias, or weight loss, and an extensive systemic review of systems was negative. He denied any recent travel. Ocular history was significant for a traumatic right eye injury sustained in a motor vehicle accident 6 years previously, with no light perception (NLP) vision. He had a history of cold sores as a child. The patient’s only medication was Effexor (Venlafaxine Hydrochloride). He had no known drug allergies. Family history was unremarkable. He was a nonsmoker, did not drink alcohol, and did not have any pets. On examination, visual acuity was NLP OD and hand motion OS, with intraocular pressures of 20 and 21 mm Hg, respectively. We were not able to assess extraocular movements or confrontation visual fields. Anterior segment examination of the left eye revealed marked corneal edema, iris hemorrhage superiorly, a 1-mm hypopyon, and a fibrin sheet in the anterior chamber. The right eye showed 2þ nuclear sclerosis and cortical cataract, as well as iris transillumination defects, with a deep and quiet anterior chamber. There was no view of the posterior segment of the left eye; however, B-scan demonstrated mild anterior vitritis and a flat retina. Fundus examination of the right eye showed disc pallor and vessel attenuation, consistent with previous examinations. Differential diagnosis included acute anterior uveitis with spillover, panuveitis, endogenous endophthalmitis, sympathetic ophthalmia, and masquerade syndromes. Investigations for toxoplasmosis, Lyme disease, syphilis, cytomegalovirus, Epstein–Barr virus, herpes simplex virus, herpes zoster virus, and tuberculosis, including PPD and chest radiograph, were performed. Blood work included human leukocyte antigen (HLA) B51, HLA B27, complete blood cell count and differential, erythrocyte sedimentation rate, and C-reactive protein. The patient was started on prednisolone eye drops every hour, dexamethasone ointment at night, homatropine eye drops 2 times a day, and oral famciclovir. The following day, the patient was more comfortable, but there was no change in his vision (hand motion at face) or clinical examination. All laboratory analyses

patient was referred to retina, and phacovitrectomy, vitreous biopsy, and intravitreal injection of vancomycin and ceftazidime were performed. On the first postoperative day, visual acuity was 6/60 OS. The biopsy material subsequently grew gram-negative bacilli of Pantoea species. The patient was started on gatifloxacin and prednisolone eye drops 4 times a day. The oral famciclovir was discontinued. On the 14th postoperative day, the patient had continued to improve with a visual acuity of 6/12 OS. The patient subsequently underwent a transesophageal echocardiogram, which was negative for endocarditis. At the time of entry, the patient’s infectious diseases consult was pending. Endogenous bacterial endophthalmitis (EBE) is a rare intraocular infection that results when blood-borne organisms breach the blood–ocular barrier. EBE accounts for approximately 2% to 6% of all endophthalmitis cases.2 Clinical presentation includes pain, reduced vision, eyelid edema, conjunctival injection and chemosis, hypopyon, elevated intraocular pressure, and poor view of the fundus.2,3 The final visual outcome is poor in most cases.2 It is often associated with immunocompromised host status from a variety of causes, including diabetes mellitus or malignancy.3 However, cases of vitreal culture-proven EBE in apparently immunocompetent, healthy individuals have been reported.4 Pantoea species are ubiquitous aerobic, gram-negative bacilli in the Enterobacteriaceae family. Although Pantoea species are phenotypically similar, multilocus sequencing may facilitate identification and classification of strains.5,6 Pantoea species are infrequently described as human pathogens, but reports are increasing. P. agglomerans is found in plants, soil, and feculent material, and is the most commonly isolated species in human infections.7 It was most associated with penetrating trauma by vegetative material and catheter-associated bacteremia.7 It has been implicated in nosocomial septicemia associated with

Fig. 1 — Follow-up B-scan ultrasound demonstrating increased vitreous opacities.

Correspondence contaminated infusion fluid,8,9 and cotton fever in intravenous drug users who filter drugs through colonized cotton.10 It most commonly leads to endophthalmitis by traumatic exposure or endogenous spread in immunocompromised hosts. All P. agglomerans strains may have similar virulence potential, independent of origin.11 They are less virulent than other gram-negative bacilli, which likely accounts for our patient’s excellent outcome. Interestingly, Pantoea infections in patients may not present with the classic signs and symptoms such as fever and leukocytosis, again underscoring the relative avirulence of the organism. P. agglomerans is even permitted as a biopesticide because of reported safe studies in animals. They have been shown to be susceptible to aminoglycosides, fluoroquinolones, broad-spectrum cephalosporins, imipenem, and trimethoprimsulfamethoxazole.6 We have identified only 4 case reports of Pantoea endophthalmitis. The first reported case was of an exogenous Enterobacter agglomerans endophthalmitis associated with a plant injury.12 Another case involved a metastatic Enterobacter agglomerans endophthalmitis after internal hemorrhoidal ligation.13 The third case involved an exogenous endophthalmitis associated with retention of a metallic foreign body in the lens after ocular trauma while using a grass mower.14 The final case was of a patient with interstitial lung disease who experienced development of bilateral endogenous Pantoea agglomerans endophthalmitis after oral corticosteroid treatment.15 This is the first reported case of an endogenous endophthalmitis caused by Pantoea in a systemically healthy patient. It is possible that the endophthalmitis resulted from a bacteremia with seeding to the eye following the patient’s prior dental procedure. The patient improved after phacovitrectomy and intravitreal injection of vancomycin and ceftazidime. Although visual prognosis is generally poor in EBE, the patient had return of vision, and thus it is possible that Pantoea species may not be as virulent as other organisms that cause endophthalmitis. Stephanie N. Kletke, * Ashley R. Brissette, † Jeffrey Gale † *Michael

G. DeGroote School of Medicine, McMaster University, Hamilton, Ont.; †Department of Ophthalmology, Queen’s University, Kingston, Ont.

Corneal findings in Parry–Romberg syndrome A 43-year-old female was referred for evaluation of right corneal opacification. The findings were noticed incidentally on review with her optometrist. She had described a slight increase in photosensitivity but was otherwise asymptomatic. She has a complex medical history that included Hashimoto thyroiditis, Wolf–Parkinson–White

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CAN J OPHTHALMOL — VOL. 49, NO. 1, FEBRUARY 2014

Correspondence to: Stephanie N. Kletke, BSc: [email protected]

REFERENCES 1. Durand ML. Endophthalmitis. Clin Microbiol Infect. 2013; 19:227-34. 2. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003;48:403-23. 3. Keynan Y, Finkelman Y, Lagace-Wiens P. The microbiology of endophthalmitis: global trends and a local perspective. Eur J Clin Microbiol Infect Dis. 2012;31:2879-86. 4. Shankar K, Gyanendra L, Hari S, Narayan SD. Culture proven endogenous bacterial endophthalmitis in apparently healthy individuals. Ocul Immunol Inflamm. 2009;17:396-9. 5. Brady C, Cleenwerck I, Venter S, Vancanneyt M, Swings J, Coutinho T. Phylogeny and identification of Pantoea species associated with plants, humans and the natural environment based on multilocus sequence analysis (MLSA). Syst Appl Microbiol. 2008;31:447-60. 6. Deletoile A, Decre D, Courant S, et al. Phylogeny and identification of Pantoea species and typing of Pantoea agglomerans strains by multilocus gene sequencing. J Clin Microbiol. 2009;47:300-10. 7. Cruz AT, Cazacu AC, Allen CH. Pantoea agglomerans, a plant pathogen causing human disease. J Clin Microbiol. 2007;45: 1989-92. 8. Maki DG, Rhame FS, Mackel DC, Bennett JV. Nationwide epidemic of septicemia caused by contaminated intravenous products. I. Epidemiologic and clinical features. Am J Med. 1976;60: 471-85. 9. Maki DG, Martin WT. Nationwide epidemic of septicemia caused by contaminated infusion products. IV. Growth of microbial pathogens in fluids for intravenous infusion. J Infect Dis. 1975;131:267-72. 10. Ferguson R, Feeney C, Chirurgi VA. Enterobacter agglomerans— associated cotton fever. Arch Intern Med. 1993;153:2381-2. 11. Volksch B, Thon S, Jacobsen ID, Gube M. Polyphasic study of plant- and clinic-associated Pantoea agglomerans strains reveals indistinguishable virulence potential. Infect Genet Evol. 2009;9:1381-91. 12. Mason GI, Bottone EJ, Podos SM. Traumatic endophthalmitis caused by an Erwinia species. Am J Ophthalmol. 1976;82:709-13. 13. Zeiter JH, Koch DD, ParkE DW 2nd, Font RL. Endogenous endophthalmitis with lenticular abscess caused by Enterobacter agglomerans (Erwinia species). Ophthalmic Surg. 1989;20:9-12. 14. Lee NE, Chung IY, Park JM. A case of Pantoea endophthalmitis. Korean J Ophthalmol. 2010;24:318-21. 15. Seok S, Jang YJ, Lee SW, Kim HC, Ha GY. A case of bilateral endogenous Pantoea Agglomerans endophthalmitis with interstitial lung disease. Korean J Ophthalmol. 2010;24:249-51. Can J Ophthalmol 2014;49:e1–e2 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.09.004

syndrome, Raynaud phenomenon, recurrent bronchitis, and right sinusitis. Her left eye was mildly amblyopic as a result of anisometropia. Recently, she has experienced development of tinnitus. Six years previously she had trauma-related loss of consciousness from a motor vehicle accident, followed shortly by development of a rapidly progressive right forehead scarlike lesion. A biopsy was done on the lesion and it was described as a benign fibrous papule. Linear scleroderma or Parry–Romberg