Metastatic choroidal abscess due to Pseudomonas aeruginosa in patients with cystic fibrosis

PSEUDOMONAL CHOROIDAL ABSCESS AFTER ROUTINE PARS PLANA VITRECTOMY IN AN IMMUNOSUPPRESSED PATIENT

PURPOSE

To describe an unusual case of pseudomonal choroidal abscess which developed after a routine pars plana vitrectomy in an immunosuppressed patient.

METHODS

Case report. A 61-year-old woman with a history of rheumatoid arthritis and ulcerative colitis on abatacept underwent pars plana vitrectomy. A few days after the patient's operation, a partially serous choroidal detachment was identified. Her choroidal detachment increased in size despite prednisone therapy, and she was taken to the operating room for repeat vitrectomy and choroidal drainage. Intraoperatively, there was no significant intraocular inflammation, but purulent whitish material was expressed during external choroidal drainage which grew Pseudomonas aeruginosa.

RESULTS

The patient was given intravenous antibiotics. Systemic infectious workup was negative for blood and urine cultures. The patient was transitioned to oral antibiotics, but had persistent eye pain after discharge and vision remained at count fingers. A computed tomography orbit scan with contrast showed persistent choroidal abscess, and intravitreal ceftazidime injections were administered. The patient's subjective pain resolved within several days of the first intravitreal injection; repeat ultrasound also showed interval resolution of the choroidal elevation. One year after the resolution of her choroidal abscess, her visual acuity was Snellen 20/250 in the affected eye.

CONCLUSION

Isolated choroidal bacterial abscess is a possible, but rare, complication of pars plana vitrectomy. Although visual prognosis is poor, especially for pseudomonal choroidal abscesses, aggressive treatment with timely choroidal drainage, systemic antibiotics, and intravitreal antibiotics may allow recovery of some ambulatory vision.

Successful non-surgical treatment of pseudomonas choroidal abscess in cystic fibrosis with previous double lung transplantation

Pseudomonas aeruginosa choroidal abscess is a rare condition which tends to affect patients with cystic fibrosis (CF) who have undergone double lung transplantation. Various surgical treatment strategies have been described but almost universally have had a dismal prognosis. We present a case of pseudomonas choroidal abscess in a CF patient with previous double lung transplantation who was managed with medical treatment, with intravitreal and systemic antibiotics, without surgical intervention, which led to successful resolution of the choroidal abscess, preservation of the eye and retention of vision.

[Bilateral 4MRGN Pseudomonas aeruginosa-associated choroidal abscesses in cystic fibrosis : Bilateral enucleation of the eyes as a last resort in a life-threatening situation]

We present a case of bilateral choroidal abscesses due to a multidrug-resistant gram negative (4MRGN) Pseudomonas aeruginosa lung colonization in a patient with cystic fibrosis under immunosuppression after lung transplantation. Bilateral choroidal and subretinal abscesses were detected by funduscopy, ultrasound, magnetic resonance imaging (MRI) and phacovitrectomy and were accompanied by bilateral acute vision loss. The diagnosis was confirmed by intraoperative subretinal biopsy. Due to therapy resistance a bilateral enucleation for life-saving purposes was performed.

Resolution of a choroidal abscess in the setting of endophthalmitis in an immunocompetent host with noninvasive treatment

PURPOSE

The purpose of this article was to report a case of Pseudomonas aeruginosa-related endophthalmitis associated with a choroidal abscess in an immunocompetent patient, with no history of lung disease or surgery that responded to noninvasive treatment and to compare it with other reported cases of P. aeruginosa-related choroidal abscesses.

METHODS

A case report.

PATIENT

An 89-year-old immunocompetent man, with a history of hypertension, treated colon cancer, treated prostate cancer, total hip replacement, cataracts, a recent fall, and no history of cystic fibrosis or other lung disease, presents with swelling and congestion of the left eye, conjunctival ulcer, and with later findings of choroidal lesion. The lesions demonstrated pockets of mobile and nonmobile opacities, indicating a choroidal abscess.

RESULTS

Noninvasive treatment with topical and intravenous antibiotics resulted in resolution of the abscess and improvement in visual acuity, while avoiding further retinal damage. Ocular ultrasonography showed that the therapeutic course was able to successfully decrease vitreous opacities, choroidal thickenings, and orbital irregularities. Blood cultures and ocular swabs were positive of P. aeruginosa.

CONCLUSION

An elderly immunocompetent patient presenting with Pseudomonas endogenous endophthalmitis-associated choroidal abscess had favorable anatomical and visual outcomes after treatment with only intravenous and topical antibiotics.

Successful treatment of a large choroidal abscess in an immunocompetent child. Treatment of a choroidal abscess

BACKGROUND

We report the case of a systemically well 4-year-old Aboriginal boy who developed a choroidal abscess after being poked in the left eye with a blunt object.

CASE REPORT

This boy presented with redness and reduced vision in the left eye after a blunt object was poked into his eye by his sibling. He was noted to have a choroidal mass which finally manifested as a choroidal abscess.

RESULTS

His initial visual acuity was 6/60, and dilated fundus examination demonstrated a localised solid-appearing choroidal elevation involving the posterior pole, including the macula. An ultrasound of the eye revealed a choroidal haematoma with an atypical appearance, whose height was 8 mm with a base of 12 mm x 10 mm. The lesion failed to resolve, and eventually resulted in orbital cellulitis that did not respond to intravenous and topical antibiotic treatment. He then went on to achieve complete visual recovery after successful management by transcleral incision, drainage and systemic antibiotic therapy.

CONCLUSION

Choroidal abscess has been described in patients who are debilitated, immunocompromised or suffer with systemic disease such as cystic fibrosis or endocarditis. This case represents a unique report of staphylococcal choroidal abscess in a healthy child that completely resolved after transcleral drainage and systemic antibiotics.

Bilateral hematogenous Pseudomonas aeruginosa endophthalmitis after lung transplantation

Pseudomonas aeruginosa commonly colonizes the airways of patients with cystic fibrosis (CF). However, the occurrence of bacteremia with metastatic infection to the eye causing endogenous endophthalmitis is very rare. In the setting of lung transplantation, the significance of P. aeruginosa bacteremia in patients with CF whose airways are colonized before transplantation is unknown. We report a case of bilateral P. aeruginosa endogenous endophthalmitis in a patient with CF after lung transplant without documented bacteremia. The patient presented with acute eye symptoms in the presence of a left atrial thrombus and the disease followed a rapidly progressive course requiring aggressive medical-surgical treatment. Typically P. aeruginosa endophthalmitis has been associated with a poor visual prognosis. However, with combined medical-surgical management this patient retained useful vision in one eye without having retinal detachment or requiring enucleation. Endogenous endophthalmitis should be considered in the differential diagnosis of ocular complaints in patients with CF after lung transplant.

Failure of systemic antibiotic in preventing sequential endogenous endophthalmitis of a bronchiectasis patient

PURPOSE

To report a rare presentation of bilateral, sequential Pseudomonas aeruginosa endogenous endophthalmitis in a woman with bronchiectasis.

DESIGN

Interventional case report.

METHODS

A 69-year-old woman with bronchiectasis developed right and then left endogenous endophthalmitis with the microbial of P. aeruginosa, even though a course of 3-week intravenous ceftazidime antibiotic was prescribed.

RESULTS

The presentation of endogenous endophthalmitis in the right eye was late, and final visual acuity was hand movements. The condition was recognized much earlier in the left eye, and the infection was treated early on with vitrectomy and intravitreal antibiotics. Visual acuity at 1 year was stable at 20/40.

CONCLUSION

Systemic antibiotic failed to eradicate the primary source of Pseudomonas infection in the bronchiectasis patient. Unusual, painful red eye may be the presenting feature of endogenous endophthalmitis. Early vitrectomy may be considered in endogenous endophthalmitis caused by virulent pathogens such P. aeruginosa.

PSEUDOMONAS AERUGINOSA ENDOGENOUS ENDOPHTHALMITIS WITH CHOROIDAL ABSCESS IN A PATIENT WITH CYSTIC FIBROSIS

PURPOSE

To describe the clinical presentation, management, and outcome of a case of endogenous intraocular infection due to Pseudomonas aeruginosa in a patient with cystic fibrosis (CF).

METHODS

The authors describe a case of an adult patient with CF who developed an intraocular infection by P. aeruginosa.

RESULTS

Diagnosis was confirmed by culture of purulent fluid obtained by transcleral incision and drainage. The infection persisted in spite of aggressive surgical intervention including extensive endoresection of the visibly affected retina and choroid and multiple administrations of appropriate intraocular, subconjunctival, and systemic antibiotics. Eventually, the eye became blind and painful and was enucleated.

CONCLUSIONS

Endogenous intraocular infection by P. aeruginosa can occur in patients with CF who have not undergone lung transplantation. An infection of this type may be impossible to eradicate by aggressive surgical intervention and appropriate antibiotic therapy.

Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases

Endogenous bacterial endophthalmitis is a rare but serious condition that occurs when bacteria cross the blood-ocular barrier and multiply within the eye. We provide an overview of endogenous bacterial endophthalmitis by reviewing 267 reported cases and integrating this with our experience of an additional 19 cases. The majority of patients with endogenous bacterial endophthalmitis are initially misdiagnosed and many have an underlying disease known to predispose to infection. This condition is often previously undiagnosed. Blood cultures are the most frequent means of establishing the diagnosis. The most common Gram positive organisms are Staphylococcus aureus, group B streptococci, Streptococcus pneumoniae,and Listeria monocytogenes. The most common Gram negative organisms are Klebsiella spp., Escherichia coli, Pseudomonas aeruginosa, and Neisseria meningitidis. Gram negative organisms are responsible for the majority of cases reported from East Asian hospitals, but Gram positive organisms are more common in North America and Europe. The visual outcome is poor with most cases leading to blindness in the affected eye. Many patients have extraocular foci of infection, with an associated mortality rate of 5%. The outcome of endogenous bacterial endophthalmitis has not improved in 55 years and clinicians need to have a high level of awareness of this commonly misdiagnosed condition.