Streptococcus salivarius endogenous endophthalmitis

Abstract

We describe a case of endogenous endophthalmitis in an elderly man caused by Streptococcus salivarius An 88-year-old male patient with diabetes with iron deficiency anaemia and history of transcatheter aortic valve implantation presented with an insidious clinical picture of atraumatic endophthalmitis. No internal or external source could be identified. Diagnostic and therapeutic vitrectomy revealed papillomacular abscess and vitreous fluids grew S. salivarius Despite lack of an identifiable source of infection, a high index of suspicion for atypical presentations is required in patients with multiple comorbidities that could weaken their immune system towards opportunistic infections. Early detection, microbiological evaluation and prompt treatment are critical to avoid disastrous outcomes. While S. salivarius has been implicated in cases of exogenous endophthalmitis, this is the first reported case of endogenous endophthalmitis due to S. salivarius.

Keywords: infectious diseases; ophthalmology; retina.

Figure 1

Slit-lamp examination of the left eye on the second day of presentation showing 360-degree mild-moderate conjunctival injection with relatively clear cornea (left), clear cornea without oedema with severe fibrinoid anterior chamber reaction and seclusio pupillae but absence of frank hypopyon (middle). B-scan ultrasonography showed non-specific vitreous inflammation and a flat retina (right).

Figure 2

Slit-lamp examination of the left eye on the third day of presentation demonstrating severe diffuse conjunctival injection with filamentous discharg, no periorbital inflammation/infection, frank hypopyon with purulent membrane covering the pupil (left). Higher magnification reveals diffuse corneal stromal and epithelial oedema with microcysts, diffuse keratic precipitates, occlusio pupillae with inflammatory white pupillary membrane, and frank hypopyon reaching 1/4 anterior chamber depth (middle). B-scan ultrasonography showed severe worsening of the vitreous inflammation with thickened posterior hyaloid and thick vitreous strands, but the retina was still flat (right).

Figure 3

Intraoperative images of the left eye at the beginning (left), after core vitrectomy (middle) and end of surgery (right). There was a large white abscess obliterating the macula with surrounding pre-retinal and intra-retinal haemorrhages, with associated optic nerve head inflammation. The retina was flat. The hazy view was due to the diffuse corneal oedema.

Figure 4

Slit-lamp examination of the left eye 3 months postoperatively showing a quiet eye with superior corneal haze and oedema (left), more apparent on slit beam illumination (middle). Colour fundus photograph showing the silicone-filled vitreous cavity, with a pale optic nerve head and residual inflammatory membranes over the posterior pole. The macular reflex is obliterated (right).