SURVEY OF OPHTHALMOLOGY VOLUME 21 • NUMBER 5 • MARCH-APRIL 1977

CLINICAL PATHOLOGICAL REVIEW MILTON M . BONIUK, EDITOR

Endogenous E . coli Endophthalmitis HANNA F . SHAMMAS, M.D .

of Iowa, Iowa City, Iowa

Department of Ophthalmology, University

Abstract . A case of Escherichia colt septicemia with associated metastatic endophthalmitis and endocarditis is presented . The ocular signs and symptoms were the initial manifestations of sepsis . Irreversible damage to the eye occurred in less than 24 hours. The pattern of metastatic bacterial endophthalmitis has changed since the introduction of potent antimicrobial agents, with an increased incidence of Gramnegative bacillemia . E. coil endophthalmitis carries a poor prognosis . Early diagnosis and systemic treatment will prevent the life-threatening complications of sepsis . (Sure Ophthalmol 21 :429-435, 1977) Key words . antibiotics • bacterial infections endocarditis • endogenous endophthalmitis • gram-negative bacilli

ndogenous endophthalmitis rarely complicates the course of Escherichia colt septicemia . Only a few cases have been reported in the literature.',', 47SS,6I,v4 During the past forty years, 102 cases of metastatic bacterial endophthalmitis were reported . These cases will be reviewed and discussed . In the present case, endophthalmitis was the presenting clinical sign of an E . colt septicemia in a 70-year-old diabetic patient . There was a simultaneous endocarditis .

E

Case Report A 70-year-old white male was admitted to the University of Iowa Hospital on January 21, 1975, because of sudden onset of blindness in his right eye . For the past 15 years, he has had diabetes poorly controlled by diet and hypoglycemic agents . In 1972, he underwent a transurethral prostatectomy . However, the patient

diabetes mellitus Escherichia colt •

continued to complain of mild voiding symptoms including hesitancy, frequency, dysuria and terminal dribbling- In August, 1974, he developed congestive heart failure and was treated with digitalis (Digoxin®) and furosemide (Lasix®) . Ten days before his admission, the patient developed high fever which was attributed to an upper respiratory infection . He was treated symptomatically by antipyretic medications . The fever subsided in three days . On January 20, 1975, his right eye became slightly painful and injected . The following day he had lost all perception of light in this eye . On admission, the temperature was 37 .5°C, the blood pressure was 160/80 mm Hg and the pulse rate was 84/min . Cardiovascular examination revealed a soft grade I/VI systolic ejection murmur best heard at the left sternal border . The chest was clear . The remainder of the physical examination

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Surv Ophthalmol 21 (5) March-April 1977

was negative . Ophthalmological examination revealed a normal left eye with a visual acuity of 6/9 . The right eye was blind, the lids swollen, the conjunctiva chemotic and injected and the cornea edematous . Fibrinous material was present in the anterior chamber and a hypopyon filled its lower third . The lens and the posterior segment of the eye could not be seen . The intraocular pressure was 33 mm Hg by applanation . Echographic examination of the right globe showed diffuse vitreous opacities denser in the lower half. These opacities were consistent with cellular infiltration . Paracentesis of the right anterior chamber was performed . Giemsa stain of the aqueous fluid revealed many polymorphonuclear leukocytes . No organisms were seen with the Gram stain . The aqueous fluid streaked out on agar plates did not grow any organism . Pertinent laboratory data included a white blood cell count of 22,220 with a shift to the left, FBS = 293 mg per 100 ml, BUN = 27 mg per 100 ml, creatine = 1 .3 mg per 100 ml ; electrolytes were within normal limits and the sedimentation rate was 53 mm in the first hour . Urinalysis showed 20 to 30 white blood cells by high power field and 2+ sugar . Urine culture grew Escherichia coli. The EKG was within normal limits and the chest X-ray was negative . A subconjunctival injection of gentamicin 20 mg and dexamethasone 2 mg was given . Gentamicin 0 .3% and polymyxin eye drops were then applied every two hours and cyclopentolate (Cyclogylt) 1% twice daily . Acetazolamid 250 mg was given by mouth every six hours . Forty-eight hours later, there was no improvement in the condition of the right eye. Enucleation of the globe was performed on January 24, 1975 . Histopathologic examination of the enucleated globe confirmed the diagnosis of purulent endophthalmitis . Polymorphonuclear leukocytes and fibrinous material filled the anterior chamber and vitreous . The iris, ciliary body and choroid were densely infiltrated with polymorphonuclear leukocytes . The retina was dissolved by the inflammatory process and the few remnants identified in the posterior pole were necrotic (Figs . 1 and 2) . The sclera was intact . Gram-negative bacilli were found in the vitreous and the culture from the vitreal abscess grew Escherichia coli.

Twenty-four hours following enucleation, the patient's temperature rose to 39°C with shaking chills . The heart murmur shifted from an early systolic Grade I/VI to a holosystolic Grade IV/VI . The electrocardiogram showed non-specific T-wave changes . Blood cultures grew E. coli . The clinical diagnosis of E . coli endocarditis with septicemia was made . The patient received daily ampicillin 2 g intravenously every 4 hours, kanamycin 500 mg intravenously every 12 hours and probenecid 500 mg by mouth twice daily . The temperature decreased gradually in 10 days to 37°C . The patient's urinary symptoms, i .e . hesitancy, frequency and dysuria, increased during the hospitalization period . On January 31, 1975 an intravenous pyelogram was performed . The kidneys were found to be normal . The urethrogram demonstrated a stricture of the deep bullous urethra . A 14F catheter could not be introduced . The stricture was dilated with urethral dilators . The patient was maintained on systemic antibiotics for six weeks until the blood and urine cultures became sterile . Discussion Metastatic septic endophthalmitis was first recognized by Virchow 70 in 1856 . Axenfeld° provided the first case reports in 1894 . In 1922, Seguini' 8 made a thorough search of the world literature and collected 342 cases of metastatic endophthalmitis, of which only 106 had a bacteriologic confirmation . In 1933, Lumbrosol 8 added 91 cases that occurred in the ten years following Seguini's report . A review of the literature on metastatic fungal endophthalmitis has been made by Frangois and Rysselaere 26 in 1972 and Edwards et al ." in 1974 . It was felt that the increase in the incidence of ocular mycoses in the past ten years (Fig . 3) was due mainly to the widespread use of antibiotics, corticosteroids, and immunosuppressive medications . Other factors include intravenous infusions, renal transplants and cardiac surgery . From 1935 to 1975, 44 reports',',","'21, 26-29,$1,82,e{-{0,46-00,6J,66,60,s0,65,67,66,71,74,76 d escribed a total of 102 proven cases of endophthalmitis metastatic bacterial (including our case) . Of these 102 cases, 27 were bilateral . The offending microorganism was isolated either from the affected eye or



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FIG . 1 . Posterior pole of the globe showing infiltration of the choroid, retina and vitreous by polymorphonuclear leukocytes . Note the necrotic retinal remnants . (H & E X 12)

FIG .

2 . Higher power view of the necrotic retina . (H & E X 40)



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from the blood whenever the endophthalmitis complicated the course of a fulminant septicemia . The causative organisms and primary septic foci are listed in Tables 1 and 2 . A meningococcal meningitis was associated with more than 50% of the cases . Fig . 3 shows the number of cases published in the literature by decade . Meningococcal infections accounted for the majority of cases from 1935 to 1945 and then decreased markedly due to the advent of antibiotics and to the uniform sensitivity of N. meningitidis to penicillin . 'FABLE I Causative Organism in 102 Cases of Metastatic Bacterial Endophthaimitis

Number of Cases 56 14 11 9 4 2 2 I

Organism Meningococcus Pneumococcus Staphylococcus Streptococcus Escherichia Pseudomonas Proteus Paracolon Klebsiella Bacillus Clostridium

I

I 1 TABLE 2

SHAMMAS

Fig . 3 also shows that metastatic endophthalmitis due to bacteria other than N . meningitidis, especially Gram-negative bacilli (Escherichia, Pseudomonas, Proteus, Paracolon and Klebsiella), has occurred more frequently during the last twenty years . The widespread use of antimicrobial agents in the treatment of infectious diseases has been a major factor in the more frequent appearance of severe infections caused by these strains of bacteria ." , " Suppression of the normal bacterial flora by broad spectrum antibiotics has led to the emergence and proliferation of the more resistant Gram-negative bacteria . 63 E. coh septicemia usually follows urinary tract infections . It occurs frequently in debilitated elderly people with diabetes mellitus . 66 . ...57 Endophthalmitis has rarely been noted in such patients x"6 .66 58'61'74 In the present case, E. coli endophthalmitis occurred in a 70-year-old diabetic patient . The focus of infection was the urinary tract . The offending microorganism reaches the eye via the blood stream ." The embolus, usually carried by the central retinal artery, lodges in the retina . Less frequently, it lodges in the choroid or in the ciliary body if it is carried by one of the short or long posterior ciliary arteries . The severity of the retinal 70

c

T 1

Septic Focus in 102 Cases of Metastatic Bacterial Endophthalmitis

Primary Septic Focus Meningitis Skin infections Pneumonia Pyelonephritis

Puerperal Others (Osteomyelitis, Otitis, Phlebitis, Endocarditis, Ornphalitis, Unknown)

Number Organisms of Cases 59 Meningococcus (56) Pneumococcus (3) 12 Staphylococcus (7) Streptococcus (4) Bacillus (1) 9 Pneumococcus (8) Streptococcus (1) 7 Escherichia (2) Pseudomonas (2) Klebsiella (I) Paracolon (1) Proteus (I) 6 Staphylococcus (4) (2) Streptococcus 9

60

50

10

0

1935 to 1945

1945 to 1955

1955 to 1965

1965 to 1975

Years F1c . 3 . Published cases of metastatic endophthalmitis by decade : a = meningococcal infections ; b = bacterial infections excluding (a); c = fungal infections.

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lesions in our case suggests that the portal of entry was the central retinal artery, the infection being primarily a retinitis with secondary involvement of the uveal tract . The course of metastatic bacterial endophthalmitis is usually acute . In our case, the retinitis was immediately followed by a fulminant uveitis and necrosis of the intraocular tissues . The ocular manifestations are unlike those of Candida septicemia, in which the lesions are multiple, white, cotton-like, circumscribed chorioretinal exudates with filamentous borders extending into the vitreous with an accompanying overlying vitreous haze'° •' ° Massive ocular involvement with Mycobacterium tuberculosis 12,19 .23,62,73 may mimic a metastatic septic endophthalmitis and the diagnosis is difficult if the patient has no clinical or radiological evidence of active tuberculosis . The endophthalmitis caused by a nematode infestation, namely the larvae of Toxocara canis, 11,17 •' 4 .54 may be differentiated by its chronic course, its occurrence in healthy children 6 to 11 years of age, and the absence of sepsis . A necrotic choroidal melanoma rarely simulates an endophthalmitis .°° The outcome of metastatic bacterial endophthalmitis has changed with the advent of antibiotic therapy . Table 3 shows that 34 .5% of the affected eyes treated with antibiotics between 1945 and 1975 regained a useful vision, compared to only 2 .8% before 1945 . The difference is statistically significant (p < .01). None of the published cases of E . coli endophthalmitis regained any vision . Scleral involvement and spontaneous perforation of the globe were noted in one of the cases ." In our case, the eye had to be enucleated despite massive antibiotic therapy . The simultaneous occurrence of endophthalmitis and endocarditis has been previously noted, mainly during the course of septicemias caused by Streptococcus pneumoniae 97 ' 8B . °° • 80 and Pseudomonas TABLE3 Outcome of Metastatic Bacterial Endophthaimitis

Useful vision Total number of eyes Percent

1935 to 1945 2 71 2 .8

1945 to 1975 20 58 34 .5

aeroginosa .R 1 •R8 Although Escherichia coli was found to be the causative agent in I to 2% of all cases of bacterial endocarditis, 90' 4° ." , °°.7x ours was the first case in which endophthalmitis and endocarditis occurred simultaneously during the course of an E . coli septicemia . We would like to stress the importance of metastatic endophthalmitis as the initial manifestation of a generalized septicemia .$7 ' 48,80 Search for the focus of infection and early systemic treatment are mandatory to prevent the life-threatening complications of sepsis . References 1 . Almeda EM : Metastatic pneumococcic endophthalmitis secondary to pneumococcic meningitis . Am J Ophthalmol 49 :353-355, 1960 2. Aronson SB, Sussman SJ, Moore TE, et al : Corticosteroid therapy in metastatic endophthalmitis . Arch Ophthalmol 85 :61-70, 1971 3 . Axenfeld KT : Ober die eitrige metastatische ophthalmic, besonders ihre Aetiologie and prognostische Bedeutung. Albrecht von Graefes Arch Klin Ophthalmol 40 :1-129, 1894 4. Beauvieux J, Dubourg E, Lafon J, Batac : A propos d'un cas de panophtalmie a Streptocoques . J Med Bordeaux 113 :425-431, 1936 5 . Beeson PB, Westerman E : Cerebrospinal fever . Br Med J 1 :497-500, 1943 6 . Bentley F : Report of a case of endogenous panophthalmitis due to colon bacillus . Ophthalmot Record 20 :352-354, 1911 7 . Berens C, Wilson EL : Ocular conditions associated with coliform bacteria . Arch Ophthalmol 26 :816-839, 1941 8 . Bonnet P, Chauvire E, Bonnet JL : Ophtalmie metastatique au tours d'une septicemia puer perale a Staphylocoques dor6s . Bull Soc Ophtalmol Fr 3 :106-108, 1950 9 . Bouzas A, Dorkofikis N, Karanikas H : On endogenous endophthalmitis . Bull Soc Hellen Ophthalmol 36 :49-57, 1968 10 . Bowden B : Endogenous purulent bacterial e ndophthalmitis . N Z Med J 16 (Suppl) :54-61, 1964 11 . Brown DH : Ocular Toxocara canis . IIClinical review . J Ped Ophthalmol 7 :182-191, 1970 12 . Darrel RW : Acute tuberculous panophthalmitis . Arch Ophthalmol 78 :51-54, 1967 13 . Days] Y, Sood NN, Prakash P, Bhatia I : Bilateral endophthalmitis following puerperal sepsis. Orient Arch Ophthalmol 9 :258-261, 1971



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14 . Deodati F, Bee P, Labro JB, Arne JL: Panophtalmie metastatique "post abortum ." Bull Soc Ophtalmol Fr 72 :729-730, 1972 15 . De Saint-Martin R : Double uveite suppur8e au cours d' une septicemia a meningocoques sans meningite . Guerison par les sulfamides . Ann Ocul 178 :293-298, 1945 16 . Dreyer NP, Fields BN : Heroin-associated infective endocarditis . A report of 28 cases . Ann Intern Med 78 :699-702, 1973 17 . Duguid IM : Chronic endophthalmitis due to Toxocara . Br J Ophthalmol 45 :705-717, 1961 18 . Duke-Elder S : Diseases of the uveal tract . System of Ophthalmology, Vol 9, St, Louis, CV Mosby 1966, pp 54-59 19 . Dvorak-Theobald G : Acute tuberculous endophthalmitis . Am J Ophthalmol 45 :403-407, 1958 20 . Edwards JE, Foos RY, Montgomerie JZ, Guze LB : Ocular manifestations of Candida septicemia: review of seventy-six cases of hematogenous Candida endophthalmitis . Medicine 53 :47-75, 1974 21 . Ellenberger C, Sturgill BC : Endogenous Pseudomonas panophthalmitis following prostatic resection . Am J Ophthalmol 65 :607-611, 1968 22 . Finland M, Jones WF, Barnes MW : Occurrence of serious bacterial infections since introduction of antibacterial agents . JAMA 170 :2188-2197, 1959 23 . Fischer FI : Tuberkulose Panophthalmitis . Klin Monatsbl Augenheilkd 115 :324-327, 1949 24 . Frangois J, Hanssens M : Endophtalmite chronique par Toxocara Canis . Ann Oculist 205 :149-166, 1972 25 . Frangois J, Rysselaere M : Oculomycosis . Springfield, Ill ., Charles C Thomas, 1972 26 . Frantz JF, Lemp MA, Font RL, et al : Acute endogenous panophthalmitis caused by Clostridium Perfringens . Am J Ophthalmol 78:295-303, 1974 27 . Gamel JW, Allansmith MR : Metastatic staphylococcal endophthalmitis presenting as chronic iridocyclitis . Am J Ophthalmol 77 :454-458, 1974 28 . Gottsegen G : Bacterial endocarditis due to Pseudomonas Aeruginosa . JAMA 168 :1929-1930, 1958 29 . Gough MH : Metastatic panophthalmitis following commonplace surgical infections . Lancet 2 :237-238, 1956 30. Habte-Gabr E, January LE, Smith IM : Bacterial endocarditis: The need for early diagnosis . Geriatrics 28 :164-170, 1973 31 . Haider S : Metastatic endophthalmitis : A rare complication of meningococcal meningitis . Postgrad Med J 49 :63, 1973 32 . Hedges TR, McAllister R, Coriell LL, Moore W : Metastatic endophthalmitis as a complication of meningococcic meningitis . Arch Ophthalmol 55 :503-505, 1956

SHAMMAS 33 . Hewitt CB, Overholt EL, Finder RJ, Patton JF : Gram-negative septicemia in urology . J Urol 93 :299-302, 1965 34 . Howard HJ : In discussion of McKee SH : Metastatic ophthalmia in a patient with pneumonia : Bacteriologic observations . Arch Ophthalmol 15 :787, 1936 35 . Hulka JH : Metastatic pneumococcic uveoscleritis following pneumonia . Arch Ophthalmol 17 :127-134, 1937 36 . Jain MR, Sharma HR : Puerperal sepsis leading to bilateral fulminating purulent endophthalmitis with tenonitis . Br J Ophthalmol 57 :698-699, 1973 37 . Jarrett WH, Wells JA, Hyman BN : Metastatic endophthalmitis . A report of 3 cases in proven septicemia . South Med J 64 :194-198, 1971 38 . Jensen AD, Naidoff MA : Bilateral meningococcal endophthalmitis . Arch Ophthalmol 90 :396-398, 1973 39 . Johnson AH : Metastatic septic endophthalmitis. South Med J 62 :879-880, 1969 40 . Kerkenezov N : Panophthalmitis after a blood transfusion . Br J Ophthalmol 37 :632-636, 1953 41- Krause AC, Rosenberg W : Treatment of metastatic meningococcic endophthalmitis . Report of a case . Arch Ophthalmol 32 :109-112, 1944 42 . Kreitner H : Chirurgische Abteilung der Wiener Stadtischen Allgemeinen Poliklinik . Eine seltene Augenkomplikation nach sepsis . Wien Med Wochenschr 97 :177-178, 1947 43 . Laffers Z, Boszoky S : Endogenous Proteus panophthalmitis . Am J Ophthalmol 54 :83-88, 1962 44. Laval J : Metastatic panophthalmitis from pyogenic cutaneous infections . Arch Ophthalmol 18 :104-106, 1937 45 . Lazar NK : Early ocular complications of epidemic meningitis . Arch Ophthalmol 16 :847-856, 1936 46 . Lerner PI, Weinstein L : Infective endocarditis in the antibiotic era . New Engl J Med 274 :199-206, 1966 47 . Levine J : Metastatic bacillus coli panophthalmitis from calculus pyonephrosis . Arch Ophthalmol 3 :410-412, 1930 48 . Lewis PM : Eye changes in epidemic cerebrospinal meningitis: A clinical and pathologic study of 200 cases . Trans Am Ophthalmol Soc 34 :284-324, 1936 49 . Linnen HJ : Beiderseitige metastatische Ophthalmic bei einem 7 Tage alten Saugling als Folge einer intrauterin erworbenen Entzundung? Klin Monatsbl Augenheilkd 117 : 120-127, 1950 50 . Macoul KL : Pneumococcal septicemia presenting as a hypopyon . Arch Ophthalmol 81 :144-145, 1969 51 . McCabe WR, Jackson GG : Gram-negative

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Endogenous E. coli endophthalmitis.

SURVEY OF OPHTHALMOLOGY VOLUME 21 • NUMBER 5 • MARCH-APRIL 1977 CLINICAL PATHOLOGICAL REVIEW MILTON M . BONIUK, EDITOR Endogenous E . coli Endophtha...
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