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Red eye, blurry vision, and cough

Egambaram Senthilvel, MD,


FRCSEd; Chintan Shah, MD;
Bode Adebambo, MD

The 48-year-old patient also has chills and a low-grade Case Western Reserve
University, Cleveland

fever. How would you proceed with his care? senthilvelegambaram@


yahoo.com

The authors reported no


potential conflict of interest

A
relevant to this article.
48-year-old Caucasian man comes to Figure 1
your office with redness and blurring Blurry vision in right eye
of vision in his right eye that started
the day before. For 3 weeks, he has had a pro-
ductive cough with sputum, chills, and low-
grade fever. Conjunctival injection is obvious.
The view through the cornea is hazy, and
there is a creamy white, layered settlement in
the anterior chamber (FIGURE 1 ).

What do you suspect may be


causing his ailment?

The patient has a layer of pus (hypopyon) in the ante-


rior chamber of his right eye; the cornea is also cloudy.

Additional medical history • He is unemployed.


• The patient’s medical history reveals noth-
ing significant. Review of systems
• He has sustained no recent trauma to the •F
 indings from other systems are
eye. unremarkable.

Surgical history Physical examination


• The patient had surgery to repair an umbil- • The patient is alert and oriented.
ical hernia, and orthopedic surgery on his •T  emperature is 38.6ºC (101.5ºF), heart rate
figures 1 and 2 COURTESY OF EGAMBARAM SENTHILVEL, MD

left elbow and ankle. is 103 bpm, respiratory rate 20, blood pres-
sure 114/57 mm Hg.
Family history • Oxygen saturation is 95% on room air.
• His mother has chronic obstructive airway • Lungs: normal air entry bilaterally
disease; his father has hypertension. with a few crackles in right upper lung
field.
Social history • Heart: regular heart sounds, diastolic mur-
• The patient used cocaine about 20 years mur in left lower sternal border.
ago. • Abdomen: soft, nontender, nondistend-
• He has abused alcohol, and is currently ed, no organomegaly, and normal bowel
participating in an outpatient alcohol reha- sounds.
bilitation program. • Extremities show no significant edema.
Continued

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What are your next steps? What additional tests
would you order?

• The white blood cell count is 22,000/mcL;


You request an immediate ophthalmology hemoglobin, 15.3 g/dL; hematocrit, 45.4%;
consultation, which confirms that visual acu- platelets, 158,000/mcL; neutrophils,
ity in the right eye is limited to light percep- 8800/mcL; and bands of 10%.
tion. The patient’s left eye exam is normal. • Basal metabolic panel is normal.
In the slit-lamp examination of the right eye, • Electrocardiogram is normal.
the vitreous view is obscured by hypopyon • Chest x-ray film shows right upper lobe
and corneal haziness. Hypopyon signals in- infiltrate with minimal pleural effusion
flammation of the anterior uvea and iris. Hy- (FIGURE 2 ).
popyon can occur with such noninfectious
problems as corneal ulcer, Behçet’s disease,
systemic lupus erythematosus, sarcoidosis, Expanding the investigation
Patients with and lymphoma/leukemia; and with endo- You consult an infectious disease specialist,
endogenous phthalmitis or panophthalmitis due to bacte- who recommends continuing the antibiot-
endophthalmitis rial or fungal infection. ics you’ve prescribed until blood culture re-
exhibit Based on the patient’s clinical presen- sults are available. Subsequent results are
several ocular tation, you diagnose endogenous endo- positive for Streptococcus pneumoniae with
symptoms: phthalmitis, start treatment empirically with pansensitivity. The patient also undergoes
decreased vision, intravenous (IV) vancomycin, ceftriaxone, transthoracic echocardiography, revealing
redness, floaters, and moxifloxacin, and hospitalize him for a 9-mm mass on the aortic valve with asso-
headache, and further workup. ciated severe aortic valve regurgitation and
eye discharge. mild mitral valve regurgitation. The patient is
transferred to the coronary care unit within
Endophthalmitis: 12 hours of his admission.
A medical emergency Surgery is scheduled immediately. A pre-
Endophthalmitis is a bacterial or fungal in- operative transesophageal echocardiogram
fection of the vitreous or aqueous humor of
the eye. Figure 2
The exogenous form occurs with direct
inoculation of an organism into the ante-
Posterior-anterior chest x-ray
rior chamber, following penetrating or blunt
trauma to the eye, insertion of a foreign body,
rupture of the conjunctival bleb, cataract sur-
gery (usually within 1 week of surgery), or in-
traocular lens implantation.
Endogenous endophthalmitis results
from microbial seeding of the vitreous or
aqueous humor during bacterial or fungal
septicemia. The endogenous form accounts
for just 2% to 16% of all cases of endophthal-
mitis.1–3 It is also known as metastatic endo-
phthalmitis. Most of these infections arise
suddenly, and it is a vision-threatening con-
dition that should be managed as an ophthal- The patient has consolidation in the right upper lobe
mologic emergency. with minimal pleural effusion on the right side.

198 The Jour na l of Fa mily Pra ctice | APR IL 2 0 1 0 | V o l 5 9 , N o 4


Grand Rounds: RED EYE, BLURRY VISION, AND COUGH

Figure 3
Aortic valve vegetation, regurgitation
A B
images COURTESY OF ROBERT S. FINKELHOR, MD

Transesophageal echocardiography image shows a vegetation on the coronary cusp of the aortic valve (A) and
significant aortic valve regurgitation (B).

(FIGURE 3 ) confirms earlier findings and addi- abdominal abscess, cellulitis, IV drug abuse,
tionally reveals a small mitral valve vegetation. and septic arthritis;7 invasive medical proce- Endogenous
At surgery, the aortic valve is resected and re- dures such as gastrointestinal endoscopy;8 endophthalmitis
placed; a perivalvular abscess is drained. and abdominal surgery.4,9 According to our has been
Given culture results of S pneumoniae literature review, only 6 cases have been associated with
with pansensitivity, IV vancomycin is dis- reported with pneumonia as the primary long-standing
continued postoperatively, and IV ceftriax- source of bacteremia.4,5,10 medical
one and oral moxifloxacin are continued for conditions such
6 weeks and 2 weeks, respectively. The oph- Likely causative organisms as diabetes and
thalmologist had also injected vancomycin Endophthalmitis is a clinical diagnosis con- chronic renal
into the vitreous; vitreous culture was not firmed by positive culture results on aque- failure.
performed. At 6 weeks follow-up, the patient ous or vitreous samples. However, a negative
is blind in his right eye. He has also developed result does not exclude the diagnosis. As per
sensorineural hearing loss in his left ear, and Okada et al,4 causative organisms were iso-
has finished a course of steroids prescribed lated from either vitreous or blood samples in
by an ear-nose-and-throat specialist. 96% of their cases.
z Fungal organisms account for more
What we know about than 50% of all cases of endogenous endo-
endogenous endophthalmitis phthalmitis (TABLE ). Candida albicans is, by
A patient with endogenous endophthalmitis far, the most frequent cause of fungal endo-
usually exhibits several ocular symptoms: de- phthalmitis, and aspergillosis is the second
creased vision, redness, floaters, headache, most common cause.
and eye discharge.2,4 Systemic symptoms of- z Bacterial endogenous endophthal-
ten occur 3 to 7 days after the onset of ocular mitis most often occurs with gram-positive
symptoms; only half of all cases report prior organisms. However, an East Asian study by
systemic symptoms. Wong et al11 showed gram-negative organ-
isms in 70% of cases, with Klebsiella pneu-
Associated conditions to consider moniae alone being responsible in 60% of the
Endogenous endophthalmitis has been asso- cases. Endophthalmitis caused by S pneu-
ciated with long-standing medical conditions moniae usually has a poor prognosis.12
such as diabetes mellitus and chronic renal Ultrasound imaging of the eye (B-scan)
failure.4–6 In 40% of cases, endocarditis is the usually shows increased echogenicity of the
source of bacteremia.2,4 Other possible sources vitreous due to inflammation—a useful diag-
are meningitis, urinary tract infection, intra- nostic indicator when the view of the vitreous

jfponline.com Vol 59, No 4 | APRIL 2010 | The Journal of Family Practice 199
Table
Endogenous endophthalmitis:
Which organisms to suspect, and when4,9,11,15
Organism Sources of infection

Gram-positive

Staphylococcus aureus Endocarditis, skin infections

Streptococcus pneumoniae Endocarditis, pneumonia, meningitis

Streptococcus milleri Endocarditis, liver abscess

Group B Streptococcus Endocarditis

Clostridium species GI tract abscess, procedures, carcinomas

Bacillus cereus IV drug use

Gram-negative
Pseudomonas aeruginosa Abdominal abscess
Neisseria meningitides Meningitis
Escherichia coli Urinary tract or hepatobiliary system
Vancomycin plus
Klebsiella pneumoniae Urinary tract or hepatobiliary system
ceftazidime or
fluoroquinolones Fungal
are commonly Candida albicans Immunosuppression, diabetes mellitus, GI surgery,
used empirically hyperalimentation
for all forms of Aspergillosis IV drug use, cardiac surgery, organ transplant
endophthalmitis
GI, gastrointestinal; IV, intravenous
until vitreous
culture results
are available.
is obscured by anterior chamber abnormali- ract surgery or secondary to intraocular lens
ties. (This test was unavailable for our case.) implantation, randomly assigning them in a
2×2 factorial design to study groups: vitrec-
tomy vs vitreous tap, and systemic antibiotics
Doing the most to preserve vision vs no systemic antibiotics. All patients received
Preserving a patient’s vision depends on intravitreal antibiotics. The systemic antibiot-
prompt identification of the causative or- ics used were ceftazidime and amikacin. There
ganism with blood and intravitreal cultures, was no difference in final visual acuity between
and on appropriate therapy, including IV the vitrectomy and vitreous tap groups, except
and intravitreal administration of antibiot- in patients who presented with the worst vision
ics. Vitreal surgery is also a consideration. (light perception only). For these patients, vit-
No randomized control trial has studied en- rectomy significantly decreased the chance of
dogenous endophthalmitis management, severe visual loss to 20%, vs 47% in the vitreous
due to the small number of cases worldwide. tap group. The EVS also concluded that omit-
In managing endogenous endophthalmitis, ting systemic antibiotics does not compromise
most experts follow the outcome of the En- outcomes, and can reduce toxic effects, cost,
dophthalmitis Vitrectomy Study (EVS),13 in and length of hospital stay.
which immediate vitrectomy and IV antibiot- An important qualifier of the EVS report
ics were used to treat postoperative bacterial is that the study enrolled patients with ex-
endophthalmitis. ogenous endophthalmitis; no patients with
z Notable points from EVS, and a caveat. endogenous endophthalmitis were included.
EVS enrolled 420 patients who had clinical evi- Moreover, systemic antibiotics used in EVS
dence of endophthalmitis 6 weeks after cata- mainly covered gram-negative agents, even

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Grand Rounds: RED EYE, BLURRY VISION, AND COUGH

though gram-positive cocci were responsible also commonly seen in primary care. Treat-
for 94% of the cases. ment necessarily includes systemic and intra-
z Considerations in antibiotic selection. vitreal antibiotics with or without vitrectomy.
Vancomycin plus ceftazidime or fluoroqui- Immediate ophthalmologic referral is critical
nolones are commonly used empirically for to preserving vision.
all forms of endophthalmitis until vitreous z The patient in this case had a re-
culture results are available. Fourth-gener- peat transesophageal echocardiogram at 2
ation fluoroquinolones (moxifloxacin and months, and it showed a rupture in the mitral
gatifloxacin) have increased potency against valve from the small vegetation, with worsen-
gram-positive bacteria compared with levo- ing of regurgitation. The cardiothoracic sur-
floxacin, while maintaining similar potency geon attempted repair of the mitral valve, but
against gram-negative bacteria. Moxifloxa- ended up having to replace it. The infectious
cin has significantly greater ocular penetra- disease team recommended a 6-week course
tion and better gram-positive potency than of vancomycin, which the patient finished.
gatifloxacin.14 The sensorineural hearing loss in the
Patients with endogenous endophthal- patient’s left ear was profound and did
mitis receive long-term IV antibiotics to not improve after a course of oral predni-
treat the focus of systemic infection. As not- sone. Magnetic resonance imaging showed
ed earlier, this patient completed a 6-week labyrinthitis secondary to septic emboli.
course of IV ceftriaxone and 2 weeks of oral He received 2 transtympanic injections of Our patient’s
moxifloxacin. dexamethasone, but his hearing still did not hearing loss in
improve. The otolaryngology staff has dis- his left ear was
cussed the possibility of a bone-anchored profound, and
Even prompt action hearing aid. At a recent visit to the eye clinic, despite an
may not be enough the patient had no light perception in the absence of
Red eye is common in outpatient settings. affected eye, despite an absence of active active infection,
Endogenous endophthalmitis may be an infection. Enucleation of the eye is being he had no light
uncommon cause of red eye, but you should discussed. JFP perception in the
consider it when a patient also has blurry affected eye.
vision and systemic symptoms. In this in- Correspondence
Egambaram Senthilvel, MD, FRCSEd, MetroHealth Medical
stance, it was an unusual complication of Center, Case Western Reserve University, 2500 MetroHealth
community-acquired pneumonia, which is Drive, Cleveland, OH 44109; senthilvelegambaram@yahoo.com

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