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Endogenous bacterial endophthalmitis. A report of 2 cases
Endoftalmitis endógenas bacterianas. A propósito de 2 casos
M. Cubillasa,
Corresponding author
cubillasmarta@hotmail.com

Corresponding author.
, A. Sampedroa, B. Domíngueza, I. Carriob, V. Bangob, J.J. Barbóna
a Servicio de Oftalmología, Hospital San Agustín de Avilés, Avilés (Asturias), Spain
b Servicio de Medicina Interna, Hospital San Agustín de Avilés, Avilés (Asturias), Spain
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exhibiting different presentations&#44; etiologies and responses to treatment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">Female&#44; 69&#44; diabetic in treatment with insulin&#44; hypertension and ischemic cardiopathy who had undergone colonoscopy 3 and 6 months earlier due to polyps&#46; She visited the general Ophthalmology Emergency Dept&#46; due to blurred vision and pain in the left eye &#40;LE&#41; with 3 days evolution&#46; She was diagnosed with hemovitreous&#46; Twenty-four hours later&#44; the right eye &#40;RE&#41; exhibited visual acuity of 0&#46;5&#44; whereas the left eye &#40;LE&#41; exhibited hands movement VA with chemosis&#44; hypopyon&#44; and fibrin in the pupillary area&#44; nuclear cataract&#44; 45<span class="elsevierStyleHsp" style=""></span>mmHg IOP and inability to visualize fundus due to vitreous occupancy confirmed with echography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Due to suspected EE&#44; intravenous therapy was initiated with vancomycin&#44; ceftazidim and fluconazol as well as intravitreal vancomycin repeated 72<span class="elsevierStyleHsp" style=""></span>h later&#46; Blood cultures were negative&#46; Poor evolution required evisceration after 10 days&#46; The microbiological analysis of eviscerated material isolated <span class="elsevierStyleItalic">Streptococcus bovis</span>&#46; The Cardiology Dept considered there were no signs of bacterial endocarditis&#44; for which reason echocardiogram was not carried out&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">Male&#44; 76&#44; admitted to Internal Medicine exhibiting fever&#44; lumbar pain and right elbow bursitis 9 months after lumbar arthrodesis surgery &#40;reintervened one month later due to cerebrospinal fluid fistula&#41;&#46; The bursitis was punctured and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; was isolated&#46; Intravenous treatment was initiated with rifampicin and cloxacillin but 2 days after admittance the patient exhibited a painless loss of vision in the LE with finger counting VA at 3<span class="elsevierStyleHsp" style=""></span>m&#44; 1<span class="elsevierStyleHsp" style=""></span>mm hypopyon&#44; IOP of 6<span class="elsevierStyleHsp" style=""></span>mmHg&#44; tyndall and dense vitritis that prevented fundus visualization&#46; Right eye examination was normal&#44; with VA of 1&#46; Topical corticoids and antibiotics were added&#44; together with intravitreal vancomycin repeated 72<span class="elsevierStyleHsp" style=""></span>h later despite positive clinic evolution&#46; Computerized action tomography revealed a paraspinal abscess &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and blood culture as well as abscess samples gave positive for MRSA&#46; Accordingly&#44; simultaneous drainage of the abscess and elbow bursitis was performed&#44; upon which the systemic condition resolved and VA exhibited excellent evolution and recovered the value of 1&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bacterial EE is an infrequent disease with very poor visual prognostic&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> Ocular signs and symptoms are similar to exogenous endophthalmitis with diminished vision&#44; pain&#44; absence of brightness&#44; hypopyon&#44; vitritis&#44; tyndall&#44; palpebral edema and ocular hypertension&#46; Some cases are nonspecific&#44; which could lead to diagnostic error&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In addition&#44; EE presents bilaterally in 25&#37; of cases and has a mortality of 4&#37;&#44; above all if systemic antibiotics are not administered&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">When bacterial EE is suspected&#44; empirical treatment must be established with intravenous drugs which are crucial because&#44; in contrast with exogenous endophthalmitis&#44; dissemination takes place through the bloodstream&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Broad range antibiotics are generally applied&#44; such as a vancomycin for Gram&#43;&#44; ceftazidime for Gram&#8722; or fourth-generation quinolones such as moxifloxacin that cover both types of bacteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;4</span></a> Therapy seems to be more effective when associating intravitreal administration such as vancomycin &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#41; and ceftazidime &#40;2<span class="elsevierStyleHsp" style=""></span>mg&#47;0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; that can be repeated 48<span class="elsevierStyleHsp" style=""></span>h later if no clinical improvement is observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#8211;4&#44;6</span></a> The role of vitrectomy is not defined although the best results are obtained when performed with an acceptable baseline VA&#44; even more so if the bacteria is a Gram&#43; cocci&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;6</span></a> Fungal endophthalmitis suspicion requires systemic fluconazole and intravitreal amphotericin&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The definitive diagnostic of bacterial EE requires cultures to identify the germ which&#44; in blood&#44; are positive in approximately 50&#37; whereas in intraocular samples &#40;vitreous and aqueous&#41; the percentage ranges between 36 and 73&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#8211;6</span></a> The most frequent original loci are hepatic abscesses&#44; catheters&#44; genitourinary tract infections&#44; endocarditis&#44; meningitis&#44; pneumonia&#44; arthritis&#44; peritonitis and cerebral abscesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;7</span></a> If the patient presents with isolated ocular symptoms&#44; infectious tracking tests can be carried out such as abdominopelvic CAT&#44; abdominal echography&#44; echocardiography and vertebral magnetic resonance to detect hepatic abscesses&#44; endocarditis or osteomyelitis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the first patient&#44; <span class="elsevierStyleItalic">S&#46; bovis</span> was cultured in the evisceration material&#46; This bacteria is typically found in the digestive system&#44; which is consistent with previous colonoscopy that can produce temporary bacteremia&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The second case had a paraspinal abscess produced by a MRSA&#44; a complication of a lumbar arthrodesis&#44; frequently resistant to fourth-generation quinolones but not to vancomycin&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> In what concerns management&#44; not knowing the germ in the first case recommended the association of intravitreal ceftazidime with a vancomycin&#44; while in the latter case the isolation of MRSA in bursitis justified the exclusive use of intravitreal vancomycin&#44; although the excellent response did not encourage a different dosage&#46; None of the cases underwent vitreous biopsy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The end result is highly variable&#44; ranging from no perception of light or evisceration to VA similar to pre-existing values&#46; Even so&#44; despite adequate and early treatment&#44; over 50&#37; of cases end up with VA below 0&#46;1&#44; above all with Gram&#8722; bacteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors&#46;</p></span></span>"
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          "identificador" => "xres845221"
          "titulo" => "Abstract"
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              "titulo" => "Clinical cases"
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          "titulo" => "Keywords"
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        2 => array:3 [
          "identificador" => "xres845222"
          "titulo" => "Resumen"
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            0 => array:2 [
              "identificador" => "abst0015"
              "titulo" => "Casos cl&#237;nicos"
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            1 => array:2 [
              "identificador" => "abst0020"
              "titulo" => "Discusi&#243;n"
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        3 => array:2 [
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Clinical cases"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Case 1"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Case 2"
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Discussion"
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        8 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-10-04"
    "fechaAceptado" => "2017-02-06"
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      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec840104"
          "palabras" => array:5 [
            0 => "Endophthalmitis"
            1 => "Endogenous"
            2 => "Bacterial"
            3 => "Eye infections"
            4 => "Risk factors"
          ]
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec840103"
          "palabras" => array:5 [
            0 => "Endoftalmitis"
            1 => "End&#243;gena"
            2 => "Bacteriana"
            3 => "Infecci&#243;n ocular"
            4 => "Factores de riesgo"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical cases</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The cases are presented on 2 patients with bacterial endogenous endophthalmitis&#46; The first one was caused by <span class="elsevierStyleItalic">Streptococcus bovis</span>&#44; developed after colonoscopy&#44; which had a poor outcome and resulted in evisceration&#46; The second case was caused by a methicillin resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> from an arthrodesis complicated with a para-spinal abscess&#46; It had an excellent visual outcome&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Bacterial endogenous endophthalmitis is a rare&#44; but serious ocular disease that occurs when bacteria reach the eye via the bloodstream&#46; It requires a very early diagnosis based on the clinical symptoms and patient history&#46; A suitable and specific treatment with intravenous and intravitreal antibiotics may prevent a bad visual prognosis in some cases&#46;</p></span>"
        "secciones" => array:2 [
          0 => array:2 [
            "identificador" => "abst0005"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Casos cl&#237;nicos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos 2 casos cl&#237;nicos de endoftalmitis end&#243;gena bacteriana&#46; El primero causado por <span class="elsevierStyleItalic">Streptococcus bovis</span> tras la realizaci&#243;n de una colonoscopia&#44; con mala evoluci&#243;n que acab&#243; en evisceraci&#243;n&#46; El segundo debido a un <span class="elsevierStyleItalic">Staphylococcus aureus</span> meticilin resistente procedente de un absceso paraespinal que complicaba una artrodesis&#44; con excelente recuperaci&#243;n visual&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La endoftalmitis end&#243;gena bacteriana es una enfermedad poco frecuente y grave en la que bacterias procedentes de un foco primario llegan por v&#237;a sangu&#237;nea hasta el ojo&#46; El diagn&#243;stico de sospecha ha de ser lo m&#225;s precoz posible&#44; basado en la cl&#237;nica y los antecedentes del paciente&#46; Un tratamiento adecuado y espec&#237;fico con antibi&#243;ticos intravenosos e intrav&#237;treos puede evitar el mal pron&#243;stico visual en algunos casos&#46;</p></span>"
        "secciones" => array:2 [
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            "identificador" => "abst0015"
            "titulo" => "Casos cl&#237;nicos"
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          1 => array:2 [
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            "titulo" => "Discusi&#243;n"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cubillas M&#44; Sampedro A&#44; Dom&#237;nguez B&#44; Carrio I&#44; Bango V&#44; Barb&#243;n JJ&#46; Endoftalmitis end&#243;genas bacterianas&#46; A prop&#243;sito de 2 casos&#46; Arch Soc Esp Oftalmol&#46; 2017&#59;92&#58;280&#8211;282&#46;</p>"
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        "identificador" => "fig0005"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; Large chemosis with fibrin in pupil area and vitritis that prevents focus on ocular fundus&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; Lumbar spine magnetic resonance &#40;sagittal T2&#41; with paraspinal abscess measuring 11&#46;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm around the arthrodesis&#46;</p>"
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      "titulo" => "References"
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          "bibliografiaReferencia" => array:9 [
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                        ]
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            3 => array:3 [
              "identificador" => "bib0065"
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                          "etal" => false
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                            0 => "P&#46;L&#46; Cornut"
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                    0 => array:2 [
                      "titulo" => "Changes in the clinical features and prognostic factors of endogenous enfophthalmitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Lee"
                            1 => "T&#46; Um"
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                            0 => "C&#46;C&#46; Hu"
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ISSN: 21735794
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos