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Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 229-232

A case of endogenous endophthalmitis in COVID- 19 pandemic

Vitreo Retina Department, Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India

Date of Submission30-Jun-2020
Date of Acceptance25-Jul-2020
Date of Web Publication05-Aug-2020

Correspondence Address:
Sonam Verma
Dr Kishan Eye Care and Laser Surgery Center, 127 Kanchan Bagh, Opp. Hotel Crown Palace, Indore - 452 001, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_71_20

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The home isolation from lockdown has limited the exchange of microflora in community. It benefits in limiting 2019 nCOV but collateral depletion in memory-based immunity has its own devastating consequences. It triggers subclinical infections, by reactivation of dormant pathogens or evolution of normal microflora into multidrug-resistant strains, which may escalate to endogenous infections. With the following case report, as a consequence of such unfortunate circumstances, we emphasize upon timely management of endophthalmitis, an ocular emergency, on promptly ruling out inflammatory etiologies, with modifications in protocol and due precautions as per the current COVID situation. The case demonstrates rapid response to acute endophthalmitis in a tertiary eye hospital with 24 h emergency services in a megacity amidst lockdown. The condition masqueraded as uveitis initially hence appropriate treatment got delayed by a week. Immediate aqueous sample collection for microbiological investigation and medical treatment with intravitreal injection antibiotics and steroid followed by intensive therapy with topical steroids and fortified drops aided in local delivery of drugs in better concentration than commercially available vials. Further surgical intervention, provided vitreous sample for microbial testing, debulked infection from vitreous. Growth of Enterobacter hormaechi was observed in vitreous sample, uncommon in endogenous endophthalmitis. Blood sample revealed drug-resistant Staphylococcus hominis. The patient regained vision successfully from mere perception of light to 6/60 within a few weeks. Such endogenous infections are highly alarming and necessitate urgent replacement of antibiotic abuse, over the counter treatments, approaching quacks, and fear of going to hospital with meticulous management by concerned specialists under updated protocols.

Keywords: 2019 novel coronavirus, COVID-19, endogenous endophthalmitis, Enterobacter hormaechi, multidrug-resistant Staphylococcus hominis

How to cite this article:
Verma S, Walinjkar JA. A case of endogenous endophthalmitis in COVID- 19 pandemic. Apollo Med 2020;17:229-32

How to cite this URL:
Verma S, Walinjkar JA. A case of endogenous endophthalmitis in COVID- 19 pandemic. Apollo Med [serial online] 2020 [cited 2020 Oct 24];17:229-32. Available from: https://www.apollomedicine.org/text.asp?2020/17/3/229/291471

  Introduction Top

More diverse one's microbiome, better is one's immune system. The daily social interactions trigger formation of antibodies every day to fight the microbes we share in our community. Confinement and over cleanliness not only hinders this innate ability but also creates an imbalance between the microflora and common pathogens in our body.[1] As a result, subclinically, the immune system weakens with depletion in diversity of microflora which risks reactivation of dormant foci of pathogens alongside an upsurge of drug-resistant strains.[2]

The inevitable lockdown has certainly been monumental in limiting spread of 2019 novel coronavirus (2019 nCOV), but simultaneously, it brings along the aforementioned risks due to home isolation for long duration. The following case report of endogenous endophthalmitis is exemplary of a similar impact seen in Mumbai, the most populous hotspot of COVID-19 in India.

A progressive purulent inflammation of the intraocular fluids with intraocular infection of inner coats of the eye is termed as endophthalmitis, which is a sight threatening emergency. If the left untreated or insufficiently treated, it can become a systemic threat. Endogenous type attributes to 2%–8% of all cases. Hematogeneous spread is the most common route to the eye from a foci located elsewhere. Such infection is caused by own microflora in immunocompromised status or by reactivated pathogen in a host like seen in tuberculosis.[3]

  Case Report Top

A 37-year-old woman came to our emergency clinic in the third phase of lockdown, with complaint of dramatic worsening of vision since 10 days accompanied by pain and burning sensation in her left eye. On 2 days of experiencing blurring, she consulted with an ophthalmologist elsewhere and topical prednisolone acetate 1% with homatropine hypobromite 2% were prescribed, suspecting uveitis. However, within next week, the symptoms worsened and she was referred to us with high suspicion of endophthalmitis. Before this episode, she was already under treatment with dorzolamide and timolol combination topically, an anti-glaucoma medication (AGM) for recently diagnosed Posner-Schlossman syndrome (PSS)[4] in the same eye which was successfully controlling intraocular pressure (IOP) with stable vision of 6/6. The patient had no history of any ocular surgery, recent systemic illness, and denied substance abuse. She gave a history of abortion 2 years back.

On ocular examination, vision in the right eye was 6/6 with a normal IOP of 16 mm Hg in both eyes; and on slit lamp and fundus examination, the right eye was normal. Whereas from left eye she had only perception of light, which was documented to be 6/24 only a week back. Lid edema, tenderness, and thick discharge were observed. On slit lamp, severe conjunctival congestion, endothelial pigment deposits on cornea, hypopyon (mobile, 3 mm height), flare, posterior synechiae (at 8 o clock), nonreacting irregular pupil, and ruptured lens abscess were noted [Figure 1]a, [Figure 1]b, [Figure 1]c. The media was extremely hazy to view any details of posterior segment hence we did ultrasonography (B scan). The B scan of the left eye showed dense echoes in vitreous, incomplete posterior vitreous detachment, choroidal thickening with attached retina and choroid. There was no mass lesion [Figure 2]. At this point, all clinical findings strongly indicated endogenous endophthalmitis as our provisional diagnosis. The delay of 10 days is a bad prognostic factor anatomically and functionally. As emergency diagnostic and therapeutic intervention, with the help of 30 G needle, hypopyon from anterior chamber was collected and sent for microscopy, culture, and antibiotic susceptibility. It was followed by intravitreal injections of antibiotics (vancomycin, 1 mg/0.01 ml + ceftazidime, 2.25 mg/0.01 ml) and steroid (dexamethasone, 400 μg/0.01 ml) in left eye with sterile precautions on the same day. Intensive medical treatment was started with fortified eyedrops (5% vancomycin and 5% ceftazidime) and moxifloxacin (0.5%) hourly after ½ h from injection to provide first line of broad spectrum antibacterial coverage with oral combination of amoxicillin and clavulanic acid (625 mg twice daily for 5 days). For anti-inflammatory action, topical steroids (prednisolone acetate 1% hourly) and topical anti-cholinergic (2% homatropine hypobromide three times daily) were continued. For urgent surgical management, 23 G pars plana vitrectomy with lensectomy and silicone oil injection was planned with microscopy, and culture of undiluted vitreous, antimicrobial susceptibility testing of bacterial isolates, and repeat intravitreal antibiotics and steroid injections.[5]
Figure 1: (a) Preoperative slit lamp photo OS showing endothelial pigments on cornea, hypopyon, posterior synechiae and lens abscess. (b) Preoperative slit lamp photo OS showing conjunctival congestion, flare, hypopyon, and lens abscess. (c) Preoperative slit lamp photo OS showing thick discharge, chemosis, conjunctival congestion, and lens abscess

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Figure 2: Pre operative ultrasonography B scan shows dense dot and membrane echoes in entire vitreous, attached retina and thickened choroid without detachment

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In contrast to protocols to manage such emergency surgically on the same day, we had to delay for testing for 2019 n COV, as per the revised guidelines then. Along with preoperative investigations, culture and sensitivity of blood and urine samples were done. The blood culture revealed Staphylococcushominis which was highly resistant to penicillins and cephalosporins. It was sensitive to levofloxacin, clindamycin, gentamicin, ciprofloxacin, vancomycin, erythromycin, azithromycin, doxycycline, minocycline, linezolid, and cotrimoxazole. Preoperative investigations (complete blood count, bleeding time, clotting time, and electrolytes) were normal except for a mildly raised erythrocyte sedimentation rate. The patient referred to a physician to look for any systemic ailment to find endogenous source but none could be discovered clinically. The patient tested negative for 2019 nCOV, human immunodeficiency virus, hepatitis B antigen, and Australian antigen and was taken for surgery immediately.

Intraoperatively, the undiluted vitreous biopsy sample was collected with the help of a cutter at the beginning of the surgery and sent for microbiology tests. On culture, the growth of Enterobacterhormaechi was detected which surprisingly till date has been reported only in cases of postoperative or posttraumatic endophthalmitis.[6],[7] It was sensitive to piperacillin + tazobactam, cefoperazone + sulbactam, ciprofloxacin, gentamicin, amikacin, cotrimoxazole, cefepime, ceftriaxone, ertapenem, imipenem, and meropenem.

Postoperatively, oral antibiotics were switched to levofloxacin 750 mg (twice daily for 7 days) and we started oral AGM (250 mg acetazolamide two times daily under observation) and oral steroid (prednisolone 1 mg/kg body weight) which was tapered gradually as per recovery status. Rest all medications were continued except fortified vancomycin, which was switched with fortified gentamicin eyedrops (1.4%). On consecutive postoperative visits, inflammatory cells and hypopyon resolved [Figure 3] and [Figure 4]. Vision was gained up to 2/60. B scan also showed no new inflammation or membranes along with uncut peripheral vitreous and well attached retina; subsequently, choroidal folds also improved as IOP was restoring toward normalcy [Figure 5] and [Figure 6]. On indirect ophthalmoscopy, second order retinal vessels were faintly visible in early postoperative days as media became clearer (sign of subsiding inflammation). Hence, anatomical success was achieved, defined by preservation of the globe, absence of hypotony (intraocular pressure ≥5 mm Hg), attached retina, and absence of active inflammation.[3]
Figure 3: Immediate post operative slit lamp photo OS showing endothelial pigments on cornea, aphakia and red glow

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Figure 4: Early post operative slit lamp photo OS showing clear cornea and improved red glow

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Figure 5: Immediate postoperative ultrasonography B scan shows no inflammation in mid vitreous cavity, peripheral uncut vitreous and thick choroid with attached retina and choroid. Postoperative day 3

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Figure 6: Early postoperative ultrasonography B scan showing no active vitritis, uncut peripheral vitreous and resolving choroidal thickening. Postoperative day 17

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  Discussion Top

As per the history given by the patient and preoperative clinical examination, the differential diagnoses were narrowed down to endogenous bacterial endophthalmitis, recurrence of attack of PSS, posterior uveitis with spillage of inflammatory cells in anterior chamber with uveitic cataract, toxoplasmosis, toxocariasis, and Schwartz-Matsuo syndrome.[8]

PSS typically affects adults between the age of 20 and 50 years. Although the pathophysiology of PSS is still unknown, and there are several theories ranging from autoimmune to infectious origin, normal IOP suggested its recurrence highly unlikely.[4],[9] The lack of response and rather worsening with steroids in the absence of antibiotics along with rapid drop in vision ruled out uveitis. B scan, microbial culture and sensitivity of aqueous, vitreous tap and blood sample, collectively ruled in endogenous endophthalmitis due to E.hormaechi with background bacteremia caused by S.hominis.

Staphylococcal strains are part of our normal microflora of skin and may cause opportunistic infection in individuals with weak immune status. Such strain was first known to cause septicemia in 2002 and isolated from blood cultures of hospitalized patients.[10] These multidrug-resistant strains potentially cause infection by invading the human epithelial cells.[11] The blood ocular barrier comprises of epithelial cells which are known to be very well organized and have tight junctions to maintain finer retinal and choroidal blood circulation.

Our speculation is that through the bloodstream on reaching the coats of the left eye, this organism (S.hominis) adhered to the epithelial cells of the blood retinal barrier and caused cytotoxic damages breaching the tight junctions which provided an entry site for E.hormaechi to cause endogenous infection. Previously, called enteric group 75 was first termed as E. hormaechi in the year 1989. Of 23 strains identified, most of them were isolated from human sputum or wounds, except four which were isolated from blood.[12] As per literature available, eyes diagnosed with endophthalmitis due to E.hormaechi have reported extremely low chances of structural and visual recovery.[6]

However, here gradual improvement in early postoperative phase has been unprecedented and encouraging. Fortunately, the patient's awareness for understanding the nature of ocular emergency, belief to seek medical help and courage to undergo urgent surgery in the time of pandemic amidst a country wide lockdown led to prompt management. In such cases, conquering the infection is merely half the battle. Rehabilitating the vision by implanting a secondary intraocular lens and removing silicon oil needs patience to wait for the eye to become quiet and show no sign of active inflammation over a satisfactory period of minimum 3 months to plan further surgery.

  Conclusion Top

The isolations and precautions are the key to survival but not overdoing it alongside taking care of daily nutrition, exercise ensures better living, mentally and physically. Antibiotic abuse, seeking over the counter treatments, approaching quacks, and delaying in going to concerned specialties for any alarming symptoms are very widespread trends in urban and rural areas which are to be discouraged on an urgent basis. These are the very basic ways to counteract the upsurging notorious infections.

In rapidly changing COVID scenario, timely modification in protocols need to go hand in hand with ocular and systemic well-being for best outcomes with due precautions. In face of such challenging situation day-to-day, a compassionate yet meticulous approach toward the ailing is as quintessential in clinics as the tissue respect in ophthalmic operating room.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Woodhams DC, Bletz MC, Becker CG, Bender HA, Rosas DB, Diebboll H, et al. Host-associated microbiomes are predicted by immune system complexity and climate. Genome Biol 2020;21:23.  Back to cited text no. 2
Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. Endogenous endophthalmitis: Diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect 2015;5:32.  Back to cited text no. 3
Posner A, Schlossman A. Syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms. Arch Ophthal 1948;39:517-35.  Back to cited text no. 4
Sharma S, Jalali S, Adiraju MV, Gopinathan U, Das T. Sensitivity and predictability of vitreous cytology, biopsy, and membrane filter culture in endophthalmitis. Retina 1996;16:525-9.  Back to cited text no. 5
Takashi N, Kyoko I, Yoshiaki N, Hideaki K, Kiyofumi M, Kiyofumi O. An eleven-year retrospective study of endogenous bacterial endophthalmitis. J Ophthalmol 2015;2015:261310. [doi: 10.1155/2015/261310].  Back to cited text no. 6
Jayasudha R, Narendran V, Manikandan P, Prabagaran SR. Identification of polybacterial communities in patients with postoperative, posttraumatic, and endogenous endophthalmitis through 16S rRNA gene libraries. J Clin Microbiol 2014;52:1459-66.  Back to cited text no. 7
Dunn JP, Garg S/12.16. 'Uveitis/Endogenous Endophthalmitis' in Bagheri N, Wajda BN The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. India: Wolter Kluwer; 2017. p. 371.  Back to cited text no. 8
Megaw R, Agarwal PK. Posner-Schlossman syndrome. Surv Ophthalmol 2017;62:277-85.  Back to cited text no. 9
Kloos WE, George CG, Olgiate JS, Van Pelt L, McKinnon ML, Zimmer BL, et al. Staphylococcus hominis subsp. novobiosepticus subsp. nov., a novel trehalose- and N-acetyl-D-glucosamine-negative, novobiocin- and multiple-antibiotic-resistant subspecies isolated from human blood cultures. Int J Syst Bacteriol 1998;48 Pt 3:799-812.  Back to cited text no. 10
Szczuka E, Krzymińska S, Bogucka N, Kaznowski A. Multifactorial mechanisms of the pathogenesis of methicillin-resistant Staphylococcus hominis isolated from bloodstream infections. Antonie Van Leeuwenhoek 2018;111:1259-65.  Back to cited text no. 11
O'Hara CM, Steigerwalt AG, Hill BC, Farmer JJ 3rd, Fanning GR, Brenner DJ. Enterobacter hormaechei, a new species of the family Enterobacteriaceae formerly known as enteric group 75. J Clin Microbiol 1989;27:2046-9.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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