Clinical Features and Mortality of Endogenous Panophthalmitis in China: A Six-Year Study

Demographics and prognosis of patients with pyogenic liver abscess due to Klebsiella pneumonia or other species

Background

Pyogenic liver abscess (PLA) is a potentially life-threatening intra-abdominal infection. We compared the clinical features, treatments, and prognoses of patients who had Klebsiella pneumonia pyogenic liver abscess (KPPLA) and non-Klebsiella pneumonia pyogenic liver abscess (non-KPPLA).

Methods

A retrospective analysis was used to compare the medical records of KPPLA and non-KPPLA patients with positive pus cultures at a single hospital in China from January 2017 to December 2019.

Results

We examined 279 patients with definitively established PLA, 207 (74.2 %) with KPPLA, and 72 with non-KPPLA. The non-KPPLA group had a higher Charlson comorbidity index, longer hospital stay, longer duration of fever, and greater hospital costs. Multivariate analysis showed that alcohol intake (OR: 2.44, P = 0.048), cancer (OR: 4.80, P = 0.001), ICU admission (OR: 10.61, P = 0.026), resolution of fever OR: 1.04, P = 0.020), and a positive blood culture (OR: 2.87, P = 0.029) were independent predictors of primary treatment failure. Percutaneous needle aspiration (PNA) and pigtail catheter drainage (PCD) provided satisfactory outcomes, but PNA led to shorter hospital stays and reduced costs, especially in KPPLA patients whose abscesses were smaller than 10 cm.

Conclusion

KPPLA and non-KPPLA patients had some differences in comorbidities and treatment strategies, and non-KPPLA patients had a significantly worse prognosis.

A rare ocular complication of septicemia: a case series report and literature review

BACKGROUND

Septicemia that leads to ocular involvement mostly presents as endophthalmitis or panophthalmitis. Contrarily, septicemia without intraocular involvement, known as hematogenous orbital cellulitis (HOC), involves only the orbit and is an extremely rare complication of septicemia and a rare type of orbital cellulitis.

CASE PRESENTATION

Four male patients with septicemia presented with orbital involvement without intraocular infection were described in this study. They were 22 (case 1), 15 (case 2), 79 (case 3), and 30 (case 4) years old, with a mean age of 29.75 years. All patients were immunocompromised except for case 2. Cases 1 and 3 had a history of steroid use, whereas case 4 was in a post-chemotherapy myelosuppression phase. Septicemia in case 1 was community-acquired, cases 3 and 4 were hospital-acquired, and case 2 was secondary to acne squeezing. Blood cultures from cases 1, 2, and 3 were positive for Candida albicans, methicillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae, respectively. Case 4 had negative cultures; however, next-generation sequencing reported the presence of Enterococcus faecalis and Rhizopus oryzae. Case 1 had right eye involvement, and both eyes were involved in the other three cases. According to Chandler's classification, case 1 was type 2, case 2 was type 2 (OD) and type 4 (OS), and cases 3 and 4 were type 1 orbital infections. All patients had eyelids erythema, and cases 1 and 2 had mildly decreased visual acuity, proptosis, and painful and restricted ocular motility. Hospital stays ranged from 13 to 43 days (mean, 24 days). All patients received systemic antibiotic therapy based on drug sensitivity and next-generation sequencing results, in combination with multidisciplinary treatment, resulting in complete recovery of ocular and systemic signs and symptoms; no ocular surgical interventions were performed. Extraocular muscle palsy was the last symptom to resolve.

CONCLUSION

HOC is predominantly seen in immunocompromised individuals with a high proportion of hospital-acquired infections and positive cultures for pathogens. Infection control using systemic antibiotics targeted at the causative organism guarantees a favorable prognosis.

A rare case of concomitant Klebsiella pneumonia and panophthalmitis in a poorly controlled diabetic patient: the first case report from Syria

Diabetes mellitus is the most common endocrine metabolic disease. Uncontrolled diabetes affects almost all components of immunity. Diabetes mellitus patients have an increased susceptibility to infections which aggravates in the cases of uncontrolled hyperglycemia.

Case presentation

The authors present the case of a 63-year-old female patient with a history of poorly controlled type 2 diabetes. She went to the ambulance complaining of fever, poor appetite, dyspnea, cough, fatigue, and asthenia. The chest computed tomography showed the presence of bilateral ovoid infiltration densities, mostly on the upper-right side. The initial diagnosis was community-acquired pneumonia in an immunocompromised host due to poorly controlled diabetes. A swelling was observed in the right cheek and around the right eye, along with ptosis of the right eyelid. The ophthalmologist indicated the presence of panophthalmitis of the entire right eye with optic neuritis and right orbital cellulitis. The bacterial culture of bronchoalveolar lavage showed Gram-negative bacteria known as Klebsiella. After 17 days of hospitalization, the patient was discharged from the hospital on treatment with oral fluconazole, oral ciprofloxacin, and intramuscular gentamicin.

Conclusion

In conclusion, the case highlights the importance of early detection of systematic infection manifestations in diabetic patients, regarding their age, history, and other comorbidities. Ocular symptoms are highly recommended to be evaluated in this context of Klebsiella infection.

Gram-Negative Endogenous Endophthalmitis: A Systematic Review

Background: Gram-negative bacteria are causative agents of endogenous endophthalmitis (EBE). We aim to systematically review the current literature to assess the aetiologies, risk factors, and early ocular lesions in cases of Gram-negative EBE. Methods: All peer-reviewed articles between January 2002 and August 2022 regarding Gram-negative EBE were included. We conducted a literature search on PubMed and Cochrane Controlled Trials. Results: A total of 115 studies and 591 patients were included, prevalently Asian (98; 81.7%) and male (302; 62.9%). The most common comorbidity was diabetes (231; 55%). The main aetiologies were Klebsiella pneumoniae (510; 66.1%), Pseudomonas aeruginosa (111; 14.4%), and Escherichia coli (60; 7.8%). Liver abscesses (266; 54.5%) were the predominant source of infection. The most frequent ocular lesions were vitreal opacity (134; 49.6%) and hypopyon (95; 35.2%). Ceftriaxone (76; 30.9%), fluoroquinolones (14; 14.4%), and ceftazidime (213; 78.0%) were the most widely used as systemic, topical, and intravitreal anti-Gram-negative agents, respectively. The most reported surgical approaches were vitrectomy (130; 24.1%) and evisceration/exenteration (60; 11.1%). Frequently, visual acuity at discharge was no light perception (301; 55.2%). Conclusions: Gram-negative EBEs are associated with poor outcomes. Our systematic review is mainly based on case reports and case series with significant heterogeneity. The main strength is the large sample spanning over 20 years. Our findings underscore the importance of considering ocular involvement in Gram-negative infections.

Sterile endogenous panophthalmitis with uncontrolled diabetes

A female patient with type 2 diabetes in her 50s presented to casualty with a 1-day history of red, painful right eye. Visual acuity (VA) bilaterally was 6/12, but a right anterior uveitis was noted, with hazy fundal view. She was discharged on topical steroid and mydriatic drops with a 2-day follow-up. VA remained unchanged, but she developed right proptosis, restricted eye movements, lid swelling, relative afferent pupillary defect and an intraocular pressure (IOP) of 39 mm Hg. She was admitted and treated with intravenous and intravitreal antibiotics, intravenous antifungals and IOP-lowering drugs. Blood tests showed raised inflammatory markers and an HbA1c of 127 mmol/mol. Over her admission, right eye vision deteriorated to no light perception. A B-scan ultrasound revealed panophthalmitis and a retinal abscess. All investigations looking for a source were negative. Inflammatory markers settled, but despite aggressive treatment, the panophthalmitis did not improve. She was discharged with a follow-up to consider enucleation.

Risk Factors Leading to Enucleation or Evisceration in Infectious Endophthalmitis

Endophthalmitis treatment consists of intravitreal antibiotics injections and, in selected circumstances, pars plana vitrectomy. However, severe or refractory cases may require an enucleation or evisceration (ENEV). Our study seeks to identify risk factors leading to enucleation or evisceration in patients with infectious endophthalmitis. A retrospective chart review of subjects with a clinical diagnosis of infectious endophthalmitis was undertaken. The affected eyes were stratified into groups: those that underwent ENEV and those in which the eyeball was preserved (EP). The groups were compared using statistical analyses. In total, 69 eyes diagnosed with infectious endophthalmitis were included in the study. There was a higher frequency of exogenous infectious endophthalmitis in the ENEV group versus the EP group. Postsurgical infectious endophthalmitis was lower in the ENEV than in the EP group. A visual acuity of no light perception was more common in the ENEV compared to the EP group. Panophthalmitis was more frequent in the ENEV versus the EP group. Our findings suggest that eyes with endophthalmitis presenting with a visual acuity of no light perception, panophthalmitis, or exogenous etiology have a higher risk of requiring ENEV. In addition, eyes with a postsurgical etiology may be at a lower risk of requiring ENEV.