Case Presentation:
A 74‐year‐old white man with end‐stage renal disease, diabetes mellitus, coronary artery disease, congestive heart failure, and S/P pacemaker placement was admitted to the hospital with a chief complaint of painful red eyes bilaterally. The patient had been treated for 2 methicillin‐resistant Staphylococcus aureus (MRSA) permanent catheter (permcath) infections in the past 4 months. The first infection was treated with removal of the permcath and 2 weeks of vancomycin. The second infection was treated again with removal of the infected permcath and 6 weeks of vancomycin to treat presumptive endocarditis. The patient did well after the second MRSA infection and remained asymptomatic until the day before presentation, when he developed bilateral red and painful eyes associated with decreased visual acuity. The patient sought medical attention at an outpatient ophthalmology clinic. Slit‐lamp examination at that time revealed panuveitis. Because of the patient's recent bloodstream infections, there was concern for endogenous endophthalmitis, and the patient was admitted to the hospital. A physical exam on admission was significant only for bilateral conjunctival injection. Blood cultures drawn on admission subsequently grew MRSA, and the patient was placed on vancomycin. A transesophageal echocardiogram was performed and revealed vegetation on the pacemaker wire in his right atrium. CT surgery and infectious disease consults were obtained. CT surgery removed his pacemaker without complication, and the patient was discharged home on daptomycin for 6 weeks.
Discussion:
Endogenous endophthalmitis is a recognized but uncommon manifestation of systemic infections. Endophthalmitis is a clinical diagnosis. Positive aqueous, vitreous, or blood cultures help support the diagnosis, but negative cultures do not exclude it. Abroad range of causative organisms have been reported in the literature, including staphylococcus, streptococcus, nocardia, klebsiella, meningococcus, and clos‐tridium. In the United States gram‐positive endovascular infections are the most common cause; however, in Asia gram‐negative hepatobiliary infections are the most common cause. Clinical outcomes are varied and range from complete recovery to permanent blindness. In one case series 16% of patients required enucleation.
Conclusions:
This case illustrates how life‐threatening diseases can present in seemingly benign ways. Endophthalmitis is an unusual complication of systemic bacterial infections with severe consequences if left unrecognized. Patients at high risk of bacteremia (ie, IV drug users and hemodialysis patients) who present with ocular inflammation should be referred for ophthalmologic examination.
Author Disclosure:
P. Pride, None.