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Published on: February 6, 2021
Invasive Klebsiella syndrome with coexisting fungal endophthalmitis
Jayanthi Sugantheran1, Embong Zunaina2, Wan Mariny Md Kasim3
1Department of Ophthalmology and Visual Science, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia
Abstract:
Endogenous endophthalmitis accounts for approximately 5 - 10% of all endophthalmitis cases. We report a case of a middle-aged gentleman with underlying uncontrolled diabetes mellitus who presented with fever and generalised body weakness for one week. He was diagnosed with invasive Klebsiella syndrome based on blood culture with presence of bilateral pleural effusion, liver abscess, renal impairment and sphenoidal sinusitis. The patient developed sudden bilateral painless reduced vision on day two of admission. Ocular examination revealed bilateral severe anterior chamber reaction and severe vitritis that obscured the view of the fundus. Ocular B-scan ultrasonography showed multiple loculations in the posterior segment in both eyes. There was soft tissue density with calcification in the left sphenoid sinus on computed tomography of the orbit. He was treated for bilateral endogenous endophthalmitis with multiple intravitreal antibiotic injections, but showed no improvement. Functional endoscopic sinus surgery was performed and revealed that the left sphenoid sinus was filled with fungal balls. Following drainage of sphenoidal pus, there was resolution of vitritis and fundus examination showed features of underlying fungal infection with a "string of pearls" present along the vascular arcade of both eyes. The patient was diagnosed with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. In addition to repeated intravitreal antibiotic injections, he was also treated with systemic and topical antifungal therapy. At three months post treatment, the infection resolved and his vision improved from counting fingers to 6/36 bilaterally. Key messages: A middle-aged gentleman presented with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. A high index of suspicion is required for early diagnosis of fungal endophthalmitis.
Insights
A middle-aged man with uncontrolled diabetes developed bilateral endogenous endophthalmitis due to invasive Klebsiella syndrome and coexisting fungal infection. Early diagnosis of fungal endophthalmitis is crucial for effective treatment and vision recovery.
Area of Science:
- Ophthalmology
- Infectious Diseases
- Medical Mycology
Background:
- Endogenous endophthalmitis is a severe intraocular infection, with 5-10% of cases arising from endogenous sources.
- Invasive Klebsiella syndrome, characterized by systemic infection with Klebsiella species, can lead to metastatic complications, including ocular involvement.
- Uncontrolled diabetes mellitus is a significant risk factor for both invasive bacterial and fungal infections.
Observation:
- A middle-aged male with uncontrolled diabetes presented with symptoms of invasive Klebsiella syndrome and subsequently developed bilateral, sudden, painless vision loss.
- Ocular examination revealed severe bilateral anterior chamber reaction and vitritis, with B-scan ultrasonography showing posterior segment abnormalities.
- Computed tomography identified sphenoid sinusitis with soft tissue density and calcification, leading to surgical exploration.
Findings:
- Functional endoscopic sinus surgery revealed fungal balls in the sphenoid sinus, indicating a coexisting fungal infection.
- Post-drainage of the sphenoid sinus and initiation of combined antibiotic and antifungal therapy, including intravitreal injections, systemic, and topical antifungals, led to resolution of vitritis.
- Fundus examination showed characteristic "string of pearls" signs, confirming fungal endophthalmitis.
Implications:
- This case highlights the importance of considering coexisting fungal endophthalmitis in patients with invasive bacterial syndromes, particularly those with risk factors like diabetes.
- A high index of suspicion and prompt diagnostic measures, including sinus imaging and fungal cultures, are essential for early identification and management.
- Successful treatment involving combined antibiotic and antifungal therapy, alongside surgical intervention for the sinus source, resulted in significant visual improvement, underscoring the need for a comprehensive approach.
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