ENDOGENOUS SERRATIA MARCESCENS ENDOPHTHALMITIS Sonya B. Shah, MD, Alok S. Bansal, MD, Michael P. Rabinowitz, MD, Carl Park, MD, Edward H. Bedrossian, Jr., MD, Ralph C. Eagle, MD
Purpose: The purpose of this study was to describe a rare case of endogenous endophthalmitis associated with dental disease secondary to Serratia marcescens in an HIV-negative individual. Methods: Retrospective case report. Results: A 50-year-old white man with a history of intravenous drug use presented with pain and decreased vision in his right eye. Slit-lamp examination showed a hazy cornea, hypopyon with fibrin in the anterior chamber, and elevated intraocular pressure. B-scan ultrasound showed vitritis and choroidal thickening. Computed tomography showed gingival inflammation and lucencies of several teeth. Blood and urine cultures were negative, and HIV testing was negative. Echocardiography was negative for vegetations. Intravitreal culture revealed S. marcescens. Despite intravitreal and systemic antibiotics, the patient’s clinical situation rapidly deteriorated, and the eye was eviscerated. The patient underwent dental extraction and was subsequently discharged in stable condition. Conclusion: The first case of endogenous endophthalmitis secondary to S. marcescens in an otherwise healthy, HIV-negative, intravenous drug user in association with severe dental disease is reported. Serratia may be found in oral biofilm, and this mechanism should be considered in cases where other etiologies have been ruled out. RETINAL CASES & BRIEF REPORTS 8:7–9, 2014
HIV-negative individual who admitted to intravenous heroin use.
From the Wills Eye Institute, Philadelphia, Pennsylvania.
E
ndogenous endophthalmitis secondary to Serratia marcescens is a rare, rapidly progressive, severe ocular infection often leading to poor visual and anatomical outcomes. After conducting a systematic literature search using PubMed with the terms “Serratia marcescens,” “endogenous,” and “endophthalmitis,” we identified 12 reported cases of endogenous endophthalmitis secondary to S. marcescens in the English literature.1–4 The majority of reported cases occur in patients with systemic illness, recent nonocular surgery, indwelling catheters, immunocompromised status, or very rarely patients with intravenous drug use. We report the first case of endogenous S. marcescens endophthalmitis associated with dental disease in an otherwise healthy,
Case Report A 50-year-old white man presented with a 2-day history of pain, redness, and vision loss in the right eye. He denied any history of ocular surgery, trauma, contact lens wear, or medical history. The patient admitted to regular intravenous heroin use. On presentation, visual acuity was light perception in the right eye and 20/70 in the left eye. On external examination, motility of the right eye was limited in all directions of gaze, with marked periorbital edema and chemosis (Figure 1). Slit-lamp examination revealed significant corneal edema, fibrin in the anterior chamber, and a 1-mm tan-colored hypopyon. Intraocular pressure in the right eye was 30 mmHg. There was no view of the fundus; B-scan ultrasonography revealed dense vitritis and choroidal thickening (Figure 2). Examination of the left eye was normal. Systemic physical examination revealed multiple decayed teeth. The patient was afebrile and normotensive. Contrast-enhanced computed tomography demonstrated preseptal edema, scleral thickening, and lucencies of multiple teeth with inflammatory changes in the jaw. The patient was diagnosed with presumed endogenous endophthalmitis and underwent immediate vitreous aspiration and intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2 mg/0.1 mL) in the right eye. The diffuse corneal edema
None of the authors have any financial/conflicting interests to disclose. Supported by the J. Arch McNamara Research Fund. Reprint requests: Alok S. Bansal, MD, 2485 Hospital Drive, Suite 200, Mountain View, CA 94301; e-mail: [email protected]
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RETINAL CASES & BRIEF REPORTS´ 2014 VOLUME 8 NUMBER 1 increasing pain. After discussion with the patient and his family, evisceration was performed on hospital Day 3. Extraction of the patient’s 19 decayed teeth was performed by the oral and maxillofacial surgeons on hospital Day 4; these were felt to be the source of infection. The patient was discharged in stable condition with improvement in pain and orbital inflammation. Gross examination of the evisceration specimen revealed yellow translucent material around the lens and anterior vitreous and darkly pigmented uveal tissue. Microscopic examination revealed extensive areas of segmental loss of the corneal epithelium. A vitreous abscess was identified, and polymorphonuclear leukocytes were present throughout the specimen. Numerous gram-negative rods were seen in the posterior face of the vitreous, and the choroid appeared thickened and infiltrated by polymorphonuclear leukocytes (Figure 3).
Fig. 1. Clinical photograph on presentation. The hypopyon is masked by the diffuse chemosis.
precluded the option of vitrectomy as a primary intervention. Hourly 1% prednisolone acetate, fortified vancomycin (25 mg/mL), and fortified tobramycin (15 mg/mL) eye drops were started thereafter. The patient was admitted to the inpatient medical service for investigation of endogenous endophthalmitis and started on intravenous vancomycin and gentamicin. Laboratory studies revealed a white blood cell count of 22,500, 2 sets of blood and urine cultures were negative, and chest radiography was within normal limits. HIV antibodies were negative. Transesophageal echocardiogram did not reveal valvular vegetations. Oral and maxillofacial surgery consultation revealed 19 decayed teeth. Vitreous cultures grew S. marcescens that was sensitive to ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, meropenem, and piperacillin/tazobactam. In vitro testing by Kirby–Bauer methods demonstrated resistance to ampicillin, cefazolin, cefoxitin, tetracycline, and tobramycin. The topical and systemic antibiotics were tailored as a result. Despite early and appropriate therapy, the patient’s vision rapidly deteriorated to no light perception with
Fig. 2. B-scan on presentation. Note the dense vitritis with choroidal thickening.
Discussion Serratia marcescens is an opportunistic, gram-negative bacillus that has been implicated as a frequent nosocomial pathogen in respiratory and urinary tract infections.5 Other risk factors for Serratia infections include recent antibiotic exposure, diabetes, and recent surgical procedures.6,7 Of the 12 reported cases of endogenous S. marcescens endophthalmitis in the English literature, 3 occurred in neonates with sepsis, 7 in adults with either systemic illness or recent nonocular surgery, and 2 cases in patients with intravenous drug use.1–4 None of the previously reported cases had a reported history of dental disease. We report the first case of endogenous S. marcescens endophthalmitis in association with dental disease in an immunocompetent, intravenous heroin user. Of the patients with a history of intravenous drug use, one patient had a history of glomerulonephritis and mycotic aneurysms of the superior mesenteric artery with positive blood and urine cultures,3 while the second had a concurrent diagnosis of HIV and history of Candida endophthalmitis in the fellow eye.4 In contrast, our patient was found only to have severe
Fig. 3. Evisceration specimen. Note the prominent gram-negative rods (hematoxylin and eosin, ·10).
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SERRATIA ENDOPHTHALMITIS
dental disease without any medical problems, recent surgery, or recent antibiotic use and was HIV-negative. Serratia marcescens has been found in the gingival biofilm8 and it is possible that patients with dental disease may thus be more susceptible to systemic Serratia infections, as daily dental hygiene may cause transient bacteremia. This may be why the above reported patient’s blood cultures were negative. Interestingly, 8 of the 9 previously reported patients who had blood cultures performed were positive for Serratia. Regarding the yield of culture from the eye among the previous cases, of the 6 patients who had a vitreous tap performed, 4 were positive for Serratia, and of the 4 patients who had an aqueous tap performed, 3 were positive. Among the 12 previous reported cases, all patients were treated with systemic antibiotics, 4 patients were treated with intravitreal antibiotics, whereas only 2 were treated with vitrectomy. Despite early and appropriate treatment, however, the visual outcome was universally poor; all 12 eyes ultimately resulted in evisceration, enucleation, or phthisis. Given the poor view for safe pars plana vitrectomy and rapid progression with severe pain, the patient elected to have evisceration. The above case illustrates the need for a high index of suspicion for rare pathogens, such as S. marcescens, in cases with rapidly progressive fulminant endophthalmitis, despite a negative history of systemic
disease or HIV. Moreover, patients and families should be counseled regarding the generally poor prognosis of these infections despite early and appropriate treatment. Key words: endogenous endophthalmitis, Serratia marcescens, intravenous drug abuse, dental disease. References 1. Equi RA, Green WR. Endogenous Serratia marcescens endophthalmitis with dark hypopyon: case report and review. Surv Ophthalmol 2001;46:259–268. 2. Wyler DJ, Glickman MG, Brewin A. Persistent Serratia bacteremia associated with drug abuse. West J Med 1975;122:70–73. 3. Alvarez R, Adan A, Martinez JA, et al. Haematogenous Serratia marcescens endophthalmitis in an HIV-infected intravenous drug addict. Infection 1990;18:29–30. 4. Latorre G. Endogenous Serratia marcescens endophthalmitis in a preterm infant. Indian J Pediatr 2008;75:410. 5. Hejazi A, Falkiner FR. Serratia marcescens. J Med Microbiol 1997;46:903–912. 6. Bouza E, García de la Torre M, Erice A, et al. Serratia bacteremia. Diagn Microbiol Infect Dis 1987;7:237–247. 7. Parkins MD, Gregson DB. Community-acquired Serratia marcescens spinal epidural abscess in a patient without risk factors: case report and review. Can J Infect Dis Med Microbiol 2008;19:250–252. 8. Barbosa FC, Irino K, Carbonell GV, Mayer MP. Characterization of Serratia marcescens isolates from subgingival biofilm, extraoral infections and environment by prodigiosin production, serotyping, and genotyping. Oral Microbiol Immunol 2006;21:53–60.
Purpose: The purpose of this study was to describe a rare case of endogenous endophthalmitis associated with dental disease secondary to Serratia marcescens in an HIV-negative individual. Methods: Retrospective case report. Results: A 50-year-old white man with a history of intravenous drug use presented with pain and decreased vision in his right eye. Slit-lamp examination showed a hazy cornea, hypopyon with fibrin in the anterior chamber, and elevated intraocular pressure. B-scan ultrasound showed vitritis and choroidal thickening. Computed tomography showed gingival inflammation and lucencies of several teeth. Blood and urine cultures were negative, and HIV testing was negative. Echocardiography was negative for vegetations. Intravitreal culture revealed S. marcescens. Despite intravitreal and systemic antibiotics, the patient’s clinical situation rapidly deteriorated, and the eye was eviscerated. The patient underwent dental extraction and was subsequently discharged in stable condition. Conclusion: The first case of endogenous endophthalmitis secondary to S. marcescens in an otherwise healthy, HIV-negative, intravenous drug user in association with severe dental disease is reported. Serratia may be found in oral biofilm, and this mechanism should be considered in cases where other etiologies have been ruled out. RETINAL CASES & BRIEF REPORTS 8:7–9, 2014
HIV-negative individual who admitted to intravenous heroin use.
From the Wills Eye Institute, Philadelphia, Pennsylvania.
E
ndogenous endophthalmitis secondary to Serratia marcescens is a rare, rapidly progressive, severe ocular infection often leading to poor visual and anatomical outcomes. After conducting a systematic literature search using PubMed with the terms “Serratia marcescens,” “endogenous,” and “endophthalmitis,” we identified 12 reported cases of endogenous endophthalmitis secondary to S. marcescens in the English literature.1–4 The majority of reported cases occur in patients with systemic illness, recent nonocular surgery, indwelling catheters, immunocompromised status, or very rarely patients with intravenous drug use. We report the first case of endogenous S. marcescens endophthalmitis associated with dental disease in an otherwise healthy,
Case Report A 50-year-old white man presented with a 2-day history of pain, redness, and vision loss in the right eye. He denied any history of ocular surgery, trauma, contact lens wear, or medical history. The patient admitted to regular intravenous heroin use. On presentation, visual acuity was light perception in the right eye and 20/70 in the left eye. On external examination, motility of the right eye was limited in all directions of gaze, with marked periorbital edema and chemosis (Figure 1). Slit-lamp examination revealed significant corneal edema, fibrin in the anterior chamber, and a 1-mm tan-colored hypopyon. Intraocular pressure in the right eye was 30 mmHg. There was no view of the fundus; B-scan ultrasonography revealed dense vitritis and choroidal thickening (Figure 2). Examination of the left eye was normal. Systemic physical examination revealed multiple decayed teeth. The patient was afebrile and normotensive. Contrast-enhanced computed tomography demonstrated preseptal edema, scleral thickening, and lucencies of multiple teeth with inflammatory changes in the jaw. The patient was diagnosed with presumed endogenous endophthalmitis and underwent immediate vitreous aspiration and intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2 mg/0.1 mL) in the right eye. The diffuse corneal edema
None of the authors have any financial/conflicting interests to disclose. Supported by the J. Arch McNamara Research Fund. Reprint requests: Alok S. Bansal, MD, 2485 Hospital Drive, Suite 200, Mountain View, CA 94301; e-mail: [email protected]
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RETINAL CASES & BRIEF REPORTS´ 2014 VOLUME 8 NUMBER 1 increasing pain. After discussion with the patient and his family, evisceration was performed on hospital Day 3. Extraction of the patient’s 19 decayed teeth was performed by the oral and maxillofacial surgeons on hospital Day 4; these were felt to be the source of infection. The patient was discharged in stable condition with improvement in pain and orbital inflammation. Gross examination of the evisceration specimen revealed yellow translucent material around the lens and anterior vitreous and darkly pigmented uveal tissue. Microscopic examination revealed extensive areas of segmental loss of the corneal epithelium. A vitreous abscess was identified, and polymorphonuclear leukocytes were present throughout the specimen. Numerous gram-negative rods were seen in the posterior face of the vitreous, and the choroid appeared thickened and infiltrated by polymorphonuclear leukocytes (Figure 3).
Fig. 1. Clinical photograph on presentation. The hypopyon is masked by the diffuse chemosis.
precluded the option of vitrectomy as a primary intervention. Hourly 1% prednisolone acetate, fortified vancomycin (25 mg/mL), and fortified tobramycin (15 mg/mL) eye drops were started thereafter. The patient was admitted to the inpatient medical service for investigation of endogenous endophthalmitis and started on intravenous vancomycin and gentamicin. Laboratory studies revealed a white blood cell count of 22,500, 2 sets of blood and urine cultures were negative, and chest radiography was within normal limits. HIV antibodies were negative. Transesophageal echocardiogram did not reveal valvular vegetations. Oral and maxillofacial surgery consultation revealed 19 decayed teeth. Vitreous cultures grew S. marcescens that was sensitive to ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, meropenem, and piperacillin/tazobactam. In vitro testing by Kirby–Bauer methods demonstrated resistance to ampicillin, cefazolin, cefoxitin, tetracycline, and tobramycin. The topical and systemic antibiotics were tailored as a result. Despite early and appropriate therapy, the patient’s vision rapidly deteriorated to no light perception with
Fig. 2. B-scan on presentation. Note the dense vitritis with choroidal thickening.
Discussion Serratia marcescens is an opportunistic, gram-negative bacillus that has been implicated as a frequent nosocomial pathogen in respiratory and urinary tract infections.5 Other risk factors for Serratia infections include recent antibiotic exposure, diabetes, and recent surgical procedures.6,7 Of the 12 reported cases of endogenous S. marcescens endophthalmitis in the English literature, 3 occurred in neonates with sepsis, 7 in adults with either systemic illness or recent nonocular surgery, and 2 cases in patients with intravenous drug use.1–4 None of the previously reported cases had a reported history of dental disease. We report the first case of endogenous S. marcescens endophthalmitis in association with dental disease in an immunocompetent, intravenous heroin user. Of the patients with a history of intravenous drug use, one patient had a history of glomerulonephritis and mycotic aneurysms of the superior mesenteric artery with positive blood and urine cultures,3 while the second had a concurrent diagnosis of HIV and history of Candida endophthalmitis in the fellow eye.4 In contrast, our patient was found only to have severe
Fig. 3. Evisceration specimen. Note the prominent gram-negative rods (hematoxylin and eosin, ·10).
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SERRATIA ENDOPHTHALMITIS
dental disease without any medical problems, recent surgery, or recent antibiotic use and was HIV-negative. Serratia marcescens has been found in the gingival biofilm8 and it is possible that patients with dental disease may thus be more susceptible to systemic Serratia infections, as daily dental hygiene may cause transient bacteremia. This may be why the above reported patient’s blood cultures were negative. Interestingly, 8 of the 9 previously reported patients who had blood cultures performed were positive for Serratia. Regarding the yield of culture from the eye among the previous cases, of the 6 patients who had a vitreous tap performed, 4 were positive for Serratia, and of the 4 patients who had an aqueous tap performed, 3 were positive. Among the 12 previous reported cases, all patients were treated with systemic antibiotics, 4 patients were treated with intravitreal antibiotics, whereas only 2 were treated with vitrectomy. Despite early and appropriate treatment, however, the visual outcome was universally poor; all 12 eyes ultimately resulted in evisceration, enucleation, or phthisis. Given the poor view for safe pars plana vitrectomy and rapid progression with severe pain, the patient elected to have evisceration. The above case illustrates the need for a high index of suspicion for rare pathogens, such as S. marcescens, in cases with rapidly progressive fulminant endophthalmitis, despite a negative history of systemic
disease or HIV. Moreover, patients and families should be counseled regarding the generally poor prognosis of these infections despite early and appropriate treatment. Key words: endogenous endophthalmitis, Serratia marcescens, intravenous drug abuse, dental disease. References 1. Equi RA, Green WR. Endogenous Serratia marcescens endophthalmitis with dark hypopyon: case report and review. Surv Ophthalmol 2001;46:259–268. 2. Wyler DJ, Glickman MG, Brewin A. Persistent Serratia bacteremia associated with drug abuse. West J Med 1975;122:70–73. 3. Alvarez R, Adan A, Martinez JA, et al. Haematogenous Serratia marcescens endophthalmitis in an HIV-infected intravenous drug addict. Infection 1990;18:29–30. 4. Latorre G. Endogenous Serratia marcescens endophthalmitis in a preterm infant. Indian J Pediatr 2008;75:410. 5. Hejazi A, Falkiner FR. Serratia marcescens. J Med Microbiol 1997;46:903–912. 6. Bouza E, García de la Torre M, Erice A, et al. Serratia bacteremia. Diagn Microbiol Infect Dis 1987;7:237–247. 7. Parkins MD, Gregson DB. Community-acquired Serratia marcescens spinal epidural abscess in a patient without risk factors: case report and review. Can J Infect Dis Med Microbiol 2008;19:250–252. 8. Barbosa FC, Irino K, Carbonell GV, Mayer MP. Characterization of Serratia marcescens isolates from subgingival biofilm, extraoral infections and environment by prodigiosin production, serotyping, and genotyping. Oral Microbiol Immunol 2006;21:53–60.
