1040-5488/15/9207-e158/0 VOL. 92, NO. 7, PP. e158Ye160 OPTOMETRY AND VISION SCIENCE Copyright * 2015 American Academy of Optometry
CLINICAL CASE
Klebsiella Endophthalmitis as Retinal Vasculitis with Prostatic Abscess Ki Won Jin*, Eunbi Kim*, Hakyoung Kim†, and So Hyun Bae*
ABSTRACT Purpose. To describe an unusual case of endogenous Klebsiella endophthalmitis associated with prostatic abscess in an immunocompetent patient. Case Report. A 59-year-old previously healthy man presented with rapidly progressive retinal vasculitis in the left eye. He received an empirical antibiotic and antiviral agent intravenously followed by oral prednisolone until the etiology was identified; however, intraocular inflammation in the left eye continued to worsen, followed by the development of subretinal abscess in the contralateral eye. Finally, a diagnosis of endogenous Klebsiella endophthalmitis associated with prostatic abscess was made through a culture of the vitreous acquired by diagnostic vitrectomy. However, we could not save the vision of the left eye despite the intensive treatment with intravenous and intravitreal injections of antibiotics. Conclusions. Rapidly progressive retinal vasculitis could be an initial sign of endogenous Klebsiella endophthalmitis even in an immunocompetent patient. (Optom Vis Sci 2015;92:e158Ye160) Key Words: Klebsiella pneumoniae, endogenous endophthalmitis, prostatic abscess, bacteremia
K
lebsiella pneumoniae has been increasingly reported to cause endogenous endophthalmitis associated with pyogenic liver abscess in Asia.1,2 The clinical course of Klebsiella endophthalmitis is usually fulminant, resulting in complete visual loss. The early diagnosis of Klebsiella endophthalmitis is a crucial step in saving the vision. However, if a previously healthy patient shows unusual clinical features of endophthalmitis without any evidence of systemic infection, it is difficult to diagnose endogenous endophthalmitis. Herein, we report a rare case of endogenous Klebsiella endophthalmitis, initially presenting as rapidly progressive retinal vasculitis associated with prostatic abscess in an immunocompetent patient.
CASE REPORT A 59-year-old man presented with sudden painless loss of vision in his left eye that began a few hours before his visit. He had no history of ocular surgery or trauma. He had no underlying diseases including diabetes mellitus. He denied having any systemic illnesses including fever, myalgia, cough, abdominal pain, or urinary irritation. *MD † MD, PhD Department of Ophthalmology, Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea (all authors).
At the initial presentation, his corrected visual acuity was 20/20 in the right eye and 20/320 in the left eye. The evaluation of the right eye was unremarkable. Biomicroscopy of the left eye revealed 2+ anterior chamber cells and 3+ vitreous haze without hypopyon or conjunctival hyperemia. Fundus examination of the left eye showed occlusive retinal vasculitis and retinitis affecting the whole retina with moderate vitritis (Fig. 1A). There was no necrotizing retinitis. Infectious retinal vasculitis was suspected. From the laboratory analyses, the concentration of the C-reactive protein was increased at 173.0 mg/L (normal, G2.9). The other findings were within the reference range including complete blood count, coagulation profile, liver function tests, urea, and electrolytes. Serologic tests that included human immunodeficiency virus antigen/antibody as well as antibodies for toxoplasma, toxocara, cytomegalovirus, varicella zoster virus, and herpes simplex virus and the fluorescent treponemal antibody-absorption test yielded negative results. The result of chest X-ray was unremarkable. He underwent a diagnostic vitreous tap for laboratory tests that included Gram staining, microbiological cultures, and polymerase chain reaction for cytomegalovirus, varicella zoster virus, herpes simplex virus, and Epstein-Barr virus. Although the retinitis was not necrotizing, we suspected viral retinal vasculitis as acute retinal necrosis based on the clinical features such as the immunocompetence of the patient, the rapid progression, and occlusive retinal vasculopathy. However, the clinical manifestations did not match any particular disease entities. Thus,
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Klebsiella Endophthalmitis, Retinal Vasculitis, and Prostatic AbscessVJin et al. e159
FIGURE 1. Fundus photographs of both eyes. (A) The initial fundus examination of the left eye revealed occlusive retinal vasculitis and retinitis with severe intraretinal hemorrhages. (B) A localized subretinal abscess with vitritis developed subsequently in the right eye.
until the pathogen was identified, we treated the patient with an empirical antiviral agent and antibiotic. Intravenous acyclovir (15 mg kgj1 dj1) with ceftazidime (3 g/d) was administered followed by oral prednisolone (30 mg/d) for 1 week. However, the intraocular inflammation continued to worsen, resulting in intense vitritis on the third day of admission and hypopyon on the sixth day obscuring the fundus. In addition, the laboratory findings of the vitreous were all negative. Thus, we conducted a diagnostic vitrectomy. During the vitrectomy, we discovered dense inflammatory material covering the entire necrotic retina, which was not detected initially. A presumptive diagnosis of endogenous endophthalmitis was made. The undiluted vitreous sample was sent for microbiological analyses. Empirical therapy for endophthalmitis was started including intravitreal injections of vancomycin (1.0 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL). On the day of the diagnostic vitrectomy, he developed a fever of 38.0-C, followed by voiding difficulty. Blood and urine cultures were done. Gram-negative bacilli were seen after Gram staining of the vitreous. On the same day, he was treated with intravenous ceftazidime (3 g/d) based on the suggestion of the infectious disease team. After that, computed tomography (CT) of the abdomen and pelvis showed large multiloculated low-density lesions involving both prostate lobes, consistent with prostatic abscess (Fig. 2). Despite the treatment, he complained of severe ocular pain without visual improvement in the left eye resulting from sustained intraocular inflammation. On the second day, retrobulbar absolute alcohol was injected in the left eye to relieve the pain. Three days after the surgery, a localized subretinal abscess with multiple inflammatory emboli within the retinal venules was detected in the contralateral eye (Fig. 1B), which implied the development of contralateral endogenous endophthalmitis. The vision of the contralateral eye also decreased to 20/100. Thus, he was treated with intravitreal injections of vancomycin (1.0 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) in the contralateral eye.
Eventually, K. pneumoniae grew on the vitreous culture sensitive to cefazolin, cefotaxime, ceftazidime, cefoxitin, cefepime, ciprofloxacin, aztreonam, imipenem, ertapenem, amikacin, gentamicin,
FIGURE 2. Abdominal-pelvic CT scan showing the prostatic abscess (arrowhead).
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
e160 Klebsiella Endophthalmitis, Retinal Vasculitis, and Prostatic AbscessVJin et al.
amoxicillin-clavulanic acid, and piperacillin-tazobactam. Blood and urine cultures were negative for pathogens. A final diagnosis of K. pneumoniae endogenous endophthalmitis caused by prostatic abscess was made. He underwent transurethral resection of the prostate abscess. In addition, a preoperative chest X-ray detected a new lesion of patch opacity in the right middle lobe. Chest CT revealed a small lung abscess formation. Intravenous ceftazidime was ceased, and levofloxacin (750 mg/d) monotherapy was started. Intravitreal ceftazidime injections were repeated in both eyes: three in the right eye and one in the left eye. After 3 weeks of treatment, the subretinal abscess in the right eye had regressed with restoration of vision up to 20/20. The intraocular inflammation in the left eye had decreased but vision had declined to no light perception. Follow-up CT showed regression of the prostatic and lung abscesses. He was discharged to his home with follow-up ophthalmology, infectious medicine, and urology.
DISCUSSION Klebsiella pneumoniae has been increasingly reported to cause endogenous endophthalmitis associated with pyogenic liver abscess in Asia.1,2 The higher virulence of the K1 serotype of K. pneumoniae could be a factor in the increase of endogenous endophthalmitis with pyogenic liver abscess in Asia.3 However, there are few studies referring to metastatic Klebsiella endophthalmitis associated with prostatic abscess although K. pneumoniae is the major pathogen of prostatic abscess.4 Prostatic abscess is difficult to diagnose because of the absence of typical symptoms or signs, which could lead to bacteremia with metastatic complications. In this case report, the diagnosis of prostatic abscess was delayed until the patient developed a fever with difficulty voiding after the vitrectomy. The clinical course of Klebsiella endophthalmitis is usually fulminant, resulting in complete visual loss. The early diagnosis of Klebsiella endophthalmitis is a crucial step in saving the vision and prevents metastatic infections. However, if an immunocompetent patient presents unusual clinical features of intraocular inflammation without any evidence of systemic infection, it is difficult to diagnose bacterial endogenous endophthalmitis. In this case report, a healthy adult without any systemic illness or risk factors had rapidly progressive retinal vasculitis, which is extremely rare in patients with endogenous endophthalmitis. We initially suspected that viral retinal vasculitis was more likely than bacterial endophthalmitis. Although an intravenous antibiotic was combined with empirical treatment of acute retinal necrosis, the condition of the patient continued to deteriorate. Surgical intervention is usually required to treat prostatic abscess. Without surgical drainage, the efficacy of systemic antibiotics is limited to patients with a small prostatic abscess such as a monofocal abscess less than 1 cm in diameter.5 In the same manner, interventions such as intravitreal injection of antibiotics or vitrectomy are usually needed to treat endophthalmitis properly. Because systemic steroids could promote bacterial replication and seeding,6 we could infer that the insufficient treatment with antibiotics without surgical intervention combined with the steroid treatment in part contributed to the deterioration of the prostatic abscess with metastatic complications. Consequently, the delayed diagnosis of endophthalmitis and prostatic abscess along with the
invasive nature of K. pneumoniae led to the development of contralateral endophthalmitis with lung abscess. The clinical manifestations of the bilateral endophthalmitis were different from each other. Initially, the affected eye presented with occlusive retinal vasculitis, but the contralateral eye showed subretinal abscess with multiple inflammatory emboli within the retinal venules, which is also a rare condition associated with endophthalmitis. The clinical features of the initial retinal vasculitis could be a result of extensive septic emboli associated with bacteremia before the formation of abscess. Animal models of endophthalmitis have shown inflammatory cell infiltration of the retinal vasculature resulting in early clinical features of retinal periphlebitis.7 Early suspicion of septic emboli in cases with retinal vasculitis could provide an opportunity to detect an asymptomatic systemic infection. In this case report, we describe a rare case of endogenous Klebsiella endophthalmitis associated with prostatic abscess in an immunocompetent patient. A delayed diagnosis along with the invasive nature of K. pneumoniae led to the deterioration of the patient’s condition with the development of contralateral endophthalmitis and lung abscess. Clinicians should be aware that the rapid progression of retinal vasculitis could be an initial sign of endogenous Klebsiella endophthalmitis even in an immunocompetent patient. Received December 16, 2014; accepted April 10, 2015.
REFERENCES 1. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology 2000;107:1483Y91. 2. Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmology 2007;114:876Y80. 3. Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007;45:284Y93. 4. Liu KH, Lee HC, Chuang YC, Tu CA, Chang K, Lee NY, Kos WC. Prostatic abscess in southern Taiwan: another invasive infection caused predominantly by Klebsiella pneumoniae. J Microbiol Immunol Infect 2003;36:31Y6. 5. Chou YH, Tiu CM, Liu JY, Chen JD, Chiou HJ, Chiou SY, Wang JH, Yu C. Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management. Ultrasound Med Biol 2004;30:719Y24. 6. Nugent KM, Cox CD, Pesanti EL. Pseudomonas aeruginosa clearance in mice: comparison of tissue, strain, and corticosteroid effects. Infect Immun 1984;43:901Y5. 7. Miller B, Miller H, Ryan SJ. Vitreoretinal junction in infectious endophthalmitis in a primate eye. Br J Ophthalmol 1987;71:454Y7.
So Hyun Bae Department of Ophthalmology Kangnam Sacred Heart Hospital Singil-ro 1 Yeongdeungpo-gu Seoul 150-950 Korea e-mail: [email protected]
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
CLINICAL CASE
Klebsiella Endophthalmitis as Retinal Vasculitis with Prostatic Abscess Ki Won Jin*, Eunbi Kim*, Hakyoung Kim†, and So Hyun Bae*
ABSTRACT Purpose. To describe an unusual case of endogenous Klebsiella endophthalmitis associated with prostatic abscess in an immunocompetent patient. Case Report. A 59-year-old previously healthy man presented with rapidly progressive retinal vasculitis in the left eye. He received an empirical antibiotic and antiviral agent intravenously followed by oral prednisolone until the etiology was identified; however, intraocular inflammation in the left eye continued to worsen, followed by the development of subretinal abscess in the contralateral eye. Finally, a diagnosis of endogenous Klebsiella endophthalmitis associated with prostatic abscess was made through a culture of the vitreous acquired by diagnostic vitrectomy. However, we could not save the vision of the left eye despite the intensive treatment with intravenous and intravitreal injections of antibiotics. Conclusions. Rapidly progressive retinal vasculitis could be an initial sign of endogenous Klebsiella endophthalmitis even in an immunocompetent patient. (Optom Vis Sci 2015;92:e158Ye160) Key Words: Klebsiella pneumoniae, endogenous endophthalmitis, prostatic abscess, bacteremia
K
lebsiella pneumoniae has been increasingly reported to cause endogenous endophthalmitis associated with pyogenic liver abscess in Asia.1,2 The clinical course of Klebsiella endophthalmitis is usually fulminant, resulting in complete visual loss. The early diagnosis of Klebsiella endophthalmitis is a crucial step in saving the vision. However, if a previously healthy patient shows unusual clinical features of endophthalmitis without any evidence of systemic infection, it is difficult to diagnose endogenous endophthalmitis. Herein, we report a rare case of endogenous Klebsiella endophthalmitis, initially presenting as rapidly progressive retinal vasculitis associated with prostatic abscess in an immunocompetent patient.
CASE REPORT A 59-year-old man presented with sudden painless loss of vision in his left eye that began a few hours before his visit. He had no history of ocular surgery or trauma. He had no underlying diseases including diabetes mellitus. He denied having any systemic illnesses including fever, myalgia, cough, abdominal pain, or urinary irritation. *MD † MD, PhD Department of Ophthalmology, Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea (all authors).
At the initial presentation, his corrected visual acuity was 20/20 in the right eye and 20/320 in the left eye. The evaluation of the right eye was unremarkable. Biomicroscopy of the left eye revealed 2+ anterior chamber cells and 3+ vitreous haze without hypopyon or conjunctival hyperemia. Fundus examination of the left eye showed occlusive retinal vasculitis and retinitis affecting the whole retina with moderate vitritis (Fig. 1A). There was no necrotizing retinitis. Infectious retinal vasculitis was suspected. From the laboratory analyses, the concentration of the C-reactive protein was increased at 173.0 mg/L (normal, G2.9). The other findings were within the reference range including complete blood count, coagulation profile, liver function tests, urea, and electrolytes. Serologic tests that included human immunodeficiency virus antigen/antibody as well as antibodies for toxoplasma, toxocara, cytomegalovirus, varicella zoster virus, and herpes simplex virus and the fluorescent treponemal antibody-absorption test yielded negative results. The result of chest X-ray was unremarkable. He underwent a diagnostic vitreous tap for laboratory tests that included Gram staining, microbiological cultures, and polymerase chain reaction for cytomegalovirus, varicella zoster virus, herpes simplex virus, and Epstein-Barr virus. Although the retinitis was not necrotizing, we suspected viral retinal vasculitis as acute retinal necrosis based on the clinical features such as the immunocompetence of the patient, the rapid progression, and occlusive retinal vasculopathy. However, the clinical manifestations did not match any particular disease entities. Thus,
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Klebsiella Endophthalmitis, Retinal Vasculitis, and Prostatic AbscessVJin et al. e159
FIGURE 1. Fundus photographs of both eyes. (A) The initial fundus examination of the left eye revealed occlusive retinal vasculitis and retinitis with severe intraretinal hemorrhages. (B) A localized subretinal abscess with vitritis developed subsequently in the right eye.
until the pathogen was identified, we treated the patient with an empirical antiviral agent and antibiotic. Intravenous acyclovir (15 mg kgj1 dj1) with ceftazidime (3 g/d) was administered followed by oral prednisolone (30 mg/d) for 1 week. However, the intraocular inflammation continued to worsen, resulting in intense vitritis on the third day of admission and hypopyon on the sixth day obscuring the fundus. In addition, the laboratory findings of the vitreous were all negative. Thus, we conducted a diagnostic vitrectomy. During the vitrectomy, we discovered dense inflammatory material covering the entire necrotic retina, which was not detected initially. A presumptive diagnosis of endogenous endophthalmitis was made. The undiluted vitreous sample was sent for microbiological analyses. Empirical therapy for endophthalmitis was started including intravitreal injections of vancomycin (1.0 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL). On the day of the diagnostic vitrectomy, he developed a fever of 38.0-C, followed by voiding difficulty. Blood and urine cultures were done. Gram-negative bacilli were seen after Gram staining of the vitreous. On the same day, he was treated with intravenous ceftazidime (3 g/d) based on the suggestion of the infectious disease team. After that, computed tomography (CT) of the abdomen and pelvis showed large multiloculated low-density lesions involving both prostate lobes, consistent with prostatic abscess (Fig. 2). Despite the treatment, he complained of severe ocular pain without visual improvement in the left eye resulting from sustained intraocular inflammation. On the second day, retrobulbar absolute alcohol was injected in the left eye to relieve the pain. Three days after the surgery, a localized subretinal abscess with multiple inflammatory emboli within the retinal venules was detected in the contralateral eye (Fig. 1B), which implied the development of contralateral endogenous endophthalmitis. The vision of the contralateral eye also decreased to 20/100. Thus, he was treated with intravitreal injections of vancomycin (1.0 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) in the contralateral eye.
Eventually, K. pneumoniae grew on the vitreous culture sensitive to cefazolin, cefotaxime, ceftazidime, cefoxitin, cefepime, ciprofloxacin, aztreonam, imipenem, ertapenem, amikacin, gentamicin,
FIGURE 2. Abdominal-pelvic CT scan showing the prostatic abscess (arrowhead).
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
e160 Klebsiella Endophthalmitis, Retinal Vasculitis, and Prostatic AbscessVJin et al.
amoxicillin-clavulanic acid, and piperacillin-tazobactam. Blood and urine cultures were negative for pathogens. A final diagnosis of K. pneumoniae endogenous endophthalmitis caused by prostatic abscess was made. He underwent transurethral resection of the prostate abscess. In addition, a preoperative chest X-ray detected a new lesion of patch opacity in the right middle lobe. Chest CT revealed a small lung abscess formation. Intravenous ceftazidime was ceased, and levofloxacin (750 mg/d) monotherapy was started. Intravitreal ceftazidime injections were repeated in both eyes: three in the right eye and one in the left eye. After 3 weeks of treatment, the subretinal abscess in the right eye had regressed with restoration of vision up to 20/20. The intraocular inflammation in the left eye had decreased but vision had declined to no light perception. Follow-up CT showed regression of the prostatic and lung abscesses. He was discharged to his home with follow-up ophthalmology, infectious medicine, and urology.
DISCUSSION Klebsiella pneumoniae has been increasingly reported to cause endogenous endophthalmitis associated with pyogenic liver abscess in Asia.1,2 The higher virulence of the K1 serotype of K. pneumoniae could be a factor in the increase of endogenous endophthalmitis with pyogenic liver abscess in Asia.3 However, there are few studies referring to metastatic Klebsiella endophthalmitis associated with prostatic abscess although K. pneumoniae is the major pathogen of prostatic abscess.4 Prostatic abscess is difficult to diagnose because of the absence of typical symptoms or signs, which could lead to bacteremia with metastatic complications. In this case report, the diagnosis of prostatic abscess was delayed until the patient developed a fever with difficulty voiding after the vitrectomy. The clinical course of Klebsiella endophthalmitis is usually fulminant, resulting in complete visual loss. The early diagnosis of Klebsiella endophthalmitis is a crucial step in saving the vision and prevents metastatic infections. However, if an immunocompetent patient presents unusual clinical features of intraocular inflammation without any evidence of systemic infection, it is difficult to diagnose bacterial endogenous endophthalmitis. In this case report, a healthy adult without any systemic illness or risk factors had rapidly progressive retinal vasculitis, which is extremely rare in patients with endogenous endophthalmitis. We initially suspected that viral retinal vasculitis was more likely than bacterial endophthalmitis. Although an intravenous antibiotic was combined with empirical treatment of acute retinal necrosis, the condition of the patient continued to deteriorate. Surgical intervention is usually required to treat prostatic abscess. Without surgical drainage, the efficacy of systemic antibiotics is limited to patients with a small prostatic abscess such as a monofocal abscess less than 1 cm in diameter.5 In the same manner, interventions such as intravitreal injection of antibiotics or vitrectomy are usually needed to treat endophthalmitis properly. Because systemic steroids could promote bacterial replication and seeding,6 we could infer that the insufficient treatment with antibiotics without surgical intervention combined with the steroid treatment in part contributed to the deterioration of the prostatic abscess with metastatic complications. Consequently, the delayed diagnosis of endophthalmitis and prostatic abscess along with the
invasive nature of K. pneumoniae led to the development of contralateral endophthalmitis with lung abscess. The clinical manifestations of the bilateral endophthalmitis were different from each other. Initially, the affected eye presented with occlusive retinal vasculitis, but the contralateral eye showed subretinal abscess with multiple inflammatory emboli within the retinal venules, which is also a rare condition associated with endophthalmitis. The clinical features of the initial retinal vasculitis could be a result of extensive septic emboli associated with bacteremia before the formation of abscess. Animal models of endophthalmitis have shown inflammatory cell infiltration of the retinal vasculature resulting in early clinical features of retinal periphlebitis.7 Early suspicion of septic emboli in cases with retinal vasculitis could provide an opportunity to detect an asymptomatic systemic infection. In this case report, we describe a rare case of endogenous Klebsiella endophthalmitis associated with prostatic abscess in an immunocompetent patient. A delayed diagnosis along with the invasive nature of K. pneumoniae led to the deterioration of the patient’s condition with the development of contralateral endophthalmitis and lung abscess. Clinicians should be aware that the rapid progression of retinal vasculitis could be an initial sign of endogenous Klebsiella endophthalmitis even in an immunocompetent patient. Received December 16, 2014; accepted April 10, 2015.
REFERENCES 1. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology 2000;107:1483Y91. 2. Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmology 2007;114:876Y80. 3. Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007;45:284Y93. 4. Liu KH, Lee HC, Chuang YC, Tu CA, Chang K, Lee NY, Kos WC. Prostatic abscess in southern Taiwan: another invasive infection caused predominantly by Klebsiella pneumoniae. J Microbiol Immunol Infect 2003;36:31Y6. 5. Chou YH, Tiu CM, Liu JY, Chen JD, Chiou HJ, Chiou SY, Wang JH, Yu C. Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management. Ultrasound Med Biol 2004;30:719Y24. 6. Nugent KM, Cox CD, Pesanti EL. Pseudomonas aeruginosa clearance in mice: comparison of tissue, strain, and corticosteroid effects. Infect Immun 1984;43:901Y5. 7. Miller B, Miller H, Ryan SJ. Vitreoretinal junction in infectious endophthalmitis in a primate eye. Br J Ophthalmol 1987;71:454Y7.
So Hyun Bae Department of Ophthalmology Kangnam Sacred Heart Hospital Singil-ro 1 Yeongdeungpo-gu Seoul 150-950 Korea e-mail: [email protected]
Optometry and Vision Science, Vol. 92, No. 7, July 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
