A rare presentation of Klebsiella pneumoniae endogenous panophthalmitis with optic neuritis and orbital cellulitis from a urinary tract infection

Abstract

This case illustrates the rare presentation of endogenous Klebsiella pneumoniae endophthalmitis with concomitant orbital cellulitis from an acute pyelonephritis. A 59-year-old Caucasian female with type 2 diabetes mellitus was transferred from a regional hospital with decreased visual acuity, periorbital edema, photophobia, proptosis and pain of the right eye, as well as suprapubic discomfort. Initial ocular examination and B-scan ultrasonography were consistent with endophthalmitis and orbital cellulitis which lead to a vitreous tap and intravitreal antibiotics injection and systemic antibiotherapy. Vitreous and blood cultures confirmed Klebsiella pneumoniae as the causative organism. An orbital MRI showed a panophthalmitis with optic neuritis and further imaging confirmed a concomitant pyelonephritis secondary to a septic nephrolithiasis. The patient was given treatment with high-does intravenous antibiotics, oral and topical corticotherapy, and an early core pars plana vitrectomy (PPV), performed 5 days after presentation with repeat injections of antibiotics and dexamethasone. Unfortunately, two weeks following PPV, despite an initial stable postoperative course, the patient deteriorated and presented with purulent discharge from one of the vitrectomy port incision site. An emergency evisceration was performed in order to control the infection, revealing a large subretinal abscess and necrosed sclerotic tissue around the prior vitrectomy incision sites. Conclusion: This is the first case report of Klebsiella pneumoniae endophthalmitis or panophthalmitis presenting with orbital cellulitis and optic neuritis from an urinary tract infection. Prognosis is poor despite treatment including early vitrectomy.

Fig. 1

Extraocular movements 48 h following intravitreal antibiotic injection. Right eye showed important eyelid edema and erythema as well as important conjunctival erythema and chemosis. Extraocular movements were limited and painful in all directions.

Fig. 2

Right eye 48 h following intravitreal antibiotic injection: conjunctival chemosis and erythema, corneal edema, cataract with fibrin on the anterior capsule, 3–4+ cells in the anterior chamber with a 1.5 mm hypopyon.

Fig. 3

Orbital MRI in the axial (A) and coronal (B) T1- SEFS post-gadolinium administration sequence, showing a right panophthalmitis with associated optic neuritis (papillitis) and orbital cellulitis. Diffuse enhancement of sclera and ciliary body, vitreous heterogeneity with diffuse enhancement pre-septal and post-septal orbital fat was noted, with important conjunctival edema. Enhancement of the optic nerve head (white arrow) of the retrobulbar optic nerve sheath. Retrobulbar optic nerve itself was normal. No signs of an orbital collection, cavernous sinus syndrome or orbital apex syndrome was seen. SEFS: Spin echo fat suppressed.

Fig. 4

Summary of medical and surgical management of our case ^# Topical anti-hypertensive drops were used during all the follow-ups. *A B-Scan ocular ultrasound was performed almost daily. PPV: pars plana vitrectomy. PF: Pred Forte. IV: intravenous. PO: per os. AP: Abdominal-Pelvic. DIE: daily. BID: two times per day. TID: three times per day. QID: four times per day. ¹ Meropenem 2 g IV TID (on day 2, meropenem was switched for ceftriaxone for less than 24 h and was reintroduced). ²Ceftriaxone 2 g IV BID. ³Ciprofloxacin 500 mg PO BID. ⁴ Prednisone per OS. ⁵ Amoxicillin-clavulanic acid 875 mg PO BID. ⁶Ceftriaxone 2 g IV DIE. Please refer to the text for information regarding radiological findings.