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x�^^^^^x>��^^�>>>^z�^�^J>��T����^J>>��>RvE�*�f>>�0�>%>%>>���D*��*Endogenous Endophthalmitis as the Initial Manifestation of a Klebsiella Pneumoniae Liver Abscess


Khurram M. Chaudhary MD1, Tushar Suthar MD1, Adam J. Flug MD1, Brett J. Rosenblatt, MD1,2
1.  Department of Ophthalmology
Hofstra North Shore � LIJ School of Medicine
Great Neck, New York
2.  Long Island Vitreoretinal Consultants
Great Neck, New York


Corresponding Author:
Khurram Chaudhary, MD
600 Northern Blvd., Suite 220
Great Neck, NY 11021
Phone:	(516) 466-0390
Fax: 	(516) 829-0520
Email: KMChaudhary@hotmail.com


Purpose: To report a rare North American case of endogenous endophthalmitis from a Klebsiella pneumoniae liver abscess. 
Methods: A 72 year old female with no past ocular history presented to Long Island Jewish Medical Center with right eye pain, blurry vision, fever, and chills.  Initial workup revealed leukocytosis, elevated transaminases, and advanced endophthalmitis of the right eye.  A vitrectomy and lensectomy were urgently performed revealing frank pus within the eye.  Initial blood and vitreous cultures were negative.  However, a CT scan revealed an 8.5 x 7.5cm hepatic abscess.
Results: After clinical decline, the patient underwent an eventual evisceration of the right eye.  CT guided percutaneous drainage of the hepatic abscess was peformed.  Cultures of the evisceration and liver abscess were both positive for Klebsiella pneumoniae.
Conclusions: This is a reported case of endogenous endophthalmitis from a Klebsiella pneumoniae liver abscess.  In North America, most cases of endogenous endophthalmitis are due to gram-positive bacteria.  However, Klebsiella pneumoniae is a known cause of endogenous endophthalmitis, especially in East Asian countries. Based on this case and our review of the literature, we feel that the growth of Klebsiella, either in blood or in ocular aspirates mandates a careful search for hepatobiliary pathology, which may include both liver function testing and imaging studies.






Case Report

A72-year-old female presented with acute loss of vision and a red, painful right eye. Past medical history was significant for hypertension, as well as a recent root canal 10 days prior, for which she received penicillin for 5 days following the procedure.  She was evaluated by her primary care physician 4 days prior to admission for subjective fevers and chills, and was started on oral ciprofloxacin for a presumed urinary tract infection.  She took only one dose of the ciprofloxacin.  On the day prior to admission, she developed loss of vision and pain in the right eye, fever, and chills.  She had no prior ophthalmic surgery.  On presentation, vision in the affected eye was light perception.  The conjunctiva was markedly injected, and the cornea was clear.  A hypopyon was present, and posterior synechiae were present.  The vitreous was opacified, and there was no view of the retina.  B-scan ultrasonography revealed vitreous debris.  The fellow eye was unaffected.  Physical examination was unremarkable.  Urinalysis was suggestive of urinary tract infection, though the patient denied genitourinary symptoms.  Initial laboratory workup was significant for leukocytosis (WBC = 13,700), mild hypokalemia, and slightly elevated transaminases.  A presumptive diagnosis of endogenous endophthalmitis was made.  The patient was started on intravenous piperacillin/tazobactam (Zosyn) and vancomycin, as well as fortified topical vancomycin and cefazolin.  Pars plana vitrectomy and lensectomy were performed the same day, and frank pus was removed from the eye and sent for culture.  The retina was found to be detached and necrotic.  Intravitreal injections of vancomycin and ceftazidime were given.

Over the first two post-operative days, the patient developed rapidly progressive proptosis, periorbital swelling and erythema, chemosis, and marked restriction of extraocular motility, as well as a recurrent hypopyon occupying 30-40% of the anterior chamber.  The eye had no light perception at this point, and was, therefore, eviscerated.  Blood, urine, and cultures from the initial vitrectomy were all negative.  Culture from the evisceration grew out Klebsiella pneumoniae.

Following evisceration, orbital signs of infection began to resolve.  However, due to persistent leukocytosis and low grade fevers, as well as an acute rise in serum creatinine, piperacillin/tazobactam was discontinued and ciprofloxacin was started.  Renal evaluation included a CT scan of the abdomen, which incidentally revealed a large hepatic abscess.  The presence of an abscess was confirmed by magnetic resonance imaging (Figs. 1-2).  The abscess, which measured 8.5cm by 7.5cm, was drained percutaneously under CT guidance: 144cc of pus was aspirated.  Following drainage of the abscess, the patient was continued on intravenous antibiotics, and the leukocytosis resolved.  Culture of the hepatic abscess grew Klebsiella pneumoniae.

Discussion
Klebsiella pneumoniae typically acts as a pathogen of the urinary, respiratory, gastrointestinal, and hepatobiliary systems.  Hematogenous dissemination to the eye can result in endogenous Klebsiella endophthalmitis (EKE), a potentially devastating complication of gram-negative sepsis.  Eyes with Klebsiella endophthalmitis generally have a poor visual outcome despite aggressive antibiotic therapy1-3.

Endogenous bacterial endophthalmitis results from the hematogenous spread of bacteria to ocular structures.  In North America and Europe, gram-positive organisms cause most cases of endogenous endophthalmitis4,5.  Endocarditis, meningitis, and urinary tract infections are the primary infections in this population.  In East Asia, however, gram-negative organisms account for the majority of cases (70%) of endogenous endophthalmitis, with Klebsiella being responsible for close to 85% of these cases6.  Moreover, among patients with EKE, the infectious source is most frequently a pyogenic liver abscess.  Chen et al reviewed 74 cases of endogenous endophthalmitis over a 10-year period in Taiwan, and found Klebsiella to be responsible in 45 (61%).  Of the cases caused by Klebsiella, a pyogenic liver abscess was found in 39 (87%) patients3.  Sng et al reviewed 133 cases of Klebsiella septicemia, five of which developed endogenous endophthalmitis.  All five (100%) had a liver abscess7.  Kashani et al reported a case of subclinical bilateral endophthalmitis in a patient with endocarditis, lobar pneumonia, and multiple hepatic and brain abscesses due to Klebsiella pneumoniae8.

The strong association between Klebsiella liver abscesses and endogenous Klebsiella endophthalmitis has been explored extensively in the East Asian population.  Typical ocular symptoms include pain, swelling, redness, and loss of vision.  Systemic symptoms most commonly include fever and chills, and less frequently abdominal pain.  In the majority of patients, ocular involvement occurs in the setting of a known hepatic abscess.  However, a significant minority have ocular symptoms as the initial manifestation.  Yang reviewed 22 patients with EKE associate with liver abscesses, 10 (45%) of whom had ocular involvement prior to the detection of hepatobiliary disease2.

Liver abscess is the most important risk factor for the development of endophthalmitis in patients with Klebsiella bacteremia.  Diabetes has been reported as a major risk factor in the development of endophthalmitis in patients with klebsiella liver abscess and also associated with poorer outcome9,10.  Disseminated intravascular coagulation has also been documented as a risk factor in the development of endophthalmitis7.  Visual prognosis in EKE is grave, with less than 25% of patients in most reports retaining finger counting vision, despite treatment with intravitreal and intravenous antibiotics.  Early vitrectomy has been proposed as a way to improve visual prognosis.  Yoon et al performed pars plana vitrectomy with subretinal abscess drainage and silicone oil tamponade in 10 eyes with EKE.  Fifty percent achieved vision of counting fingers or better, and the retina remained attached in all eyes11.  In a 20 year retrospective study, Ang et al found patients presenting with hypopyon and unilateral involvement had poorer prognosis12.

Conclusion
Endogenous Klebsiella endophthalmitis can devastate the eye, causing rapid loss of vision and often necessitating evisceration or enucleation.  Klebsiella is an extremely rare cause of endogenous endophthalmitis in the United States.  In one major US eye hospital, a 20-year review of Klebsiella-associated endophthalmitis yielded only a single case of Klebsiella from and endogenous source13.  The East Asian experience with EKE has taught us the strong association between EKE and liver abscesses.  Based on this case and our review of the literature, we feel that the growth of Klebsiella, either in blood or in ocular aspirates mandates a careful search for hepatobiliary pathology, which may include both liver function testing and imaging studies.

References
1.  Wong JS, Chan TK, Lee HM, Chee SP.  Endogenous bacterial endophthalmitis: an East Asian experience and a reappraisal of a severe ocular affliction.  Ophthalmology. 2000 Aug;107(8):1483-91.
2.  Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM.  Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess.  Ophthalmology. 2007 May; 114(5): 876-80.
3.  Chen YJ, Kuo HK, Wu PC, Kuo ML, Tsai HH, Liu CC, Chen CH. A 10-year comparison of endogenous endophthalmitis outcomes: an East Asian experience with Klebsiella pneumoniae infection. Retina. 2004 Jun; 24(3): 383-90.
4.  Okada AA, Johnson RP, Liles WC, D'Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. 1994 May;101(5):832-8.
5. Jackson TL, Eykyn SJ, Graham EM, Stanford MR.  Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003 Jul-Aug;48(4):403-23.
6. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology. 2000 Aug;107(8):1483-91. Review.
7.  Sng CC, Jap A, Chan YH, Chee SP.  Risk factors for endogenous Klebsiella endophthalmitis in patients with Klebsiella bacteraemia: a case-control study.
Br J Ophthalmol. 2008 May;92(5):673-7.
8.  Kashani AH, Eliott D. Bilateral Klebsiella pneumoniae (K1 serotype) endogenous endophthalmitis as the presenting sign of disseminated infection. Ophthalmic Surg Lasers Imaging. 2011 Feb 10;42 Online:e12-4.
9.  Margo CE, Mames RN, Guy JR.  Endogenous Klebsiella endophthalmitis. Report of two cases and review of the literature. Ophthalmology. 1994 Jul; 101(7):  1298-301.
10.  Sheu SJ, Kung YH, Wu TT, Chang FP, Horng YH. RISK FACTORS FOR ENDOGENOUS ENDOPHTHALMITIS SECONDARY TO KLEBSIELLA PNEUMONIAE LIVER ABSCESS: 20-Year Experience in Southern Taiwan. Retina. 2011 Apr 14. [Epub ahead of print]
11.  Yoon YH, Lee SU, Sohn JH, Lee SE.  Result of early vitrectomy for endogenous Klebsiella pneumoniae endophthalmitis. Retina. 2003 Jun; 23 (3): 366-70.
12.  Ang M, Jap A, Chee SP. Prognostic factors and outcomes in endogenous Klebsiella pneumoniae endophthalmitis. Am J Ophthalmol. 2011 Feb;151(2):338-44.e2. Epub 2010 Dec 18
13.  Scott IU, Matharoo N, Flynn HW Jr, Miller D.  Endophthalmitis caused by Klebsiella species.  Am J Ophthalmol. 2004 Oct; 138(4): 662-3.

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