Abstract
Purpose: To report the first European case of endogenous endophthalmitis secondary to a liver abscess due to Klebsiella pneumoniae expressing MagA gene. Methods: A 33-year-old diabetic patient was admitted for fever and right upper quadrant abdominal pain. Abdominal computed tomography and laboratory studies were performed. On day 4 after admission, patient complained of a painful and red right eye with decreased vision. A complete ophthalmological examination, including visual acuity assessment, slit lamp examination and fundus ophthalmoscopy was started. Results: Klebsiella pneumoniae liver abscess was diagnosed and antibiotherapy initiated. Polymerase chain reaction revealed that the isolated Klebsiella pneumoniae was serotype K1 and positive for Mag A. Ophthalmological examination disclosed cells in the anterior chamber and an important vitritis. Fundus was barely visible. A diagnosis of Klebsiella pneumoniae endogenous endophthalmitis complicating liver abscess was made. Intravitreal injection of antibiotics resulted in a preservation of visual acuity. Conclusion: This report suggests that rather than being confined to Taiwan, endogenous endophthalmitis secondary to a liver abscess due to Klebsiella pneumoniae expressing MagA gene, is becoming a global problem.
Avoid common mistakes on your manuscript.
Introduction
Endogenous endophthalmitis is a rare but devastating disease. Recent reports have suggested that the incidence is increasing among Asian populations mainly in Taiwan, where the major source of infection in the past 20 years has been liver abscess, with Klebsiella pneumoniae as the causative organism [1–3]. To our knowledge, this has rarely been described outside Asia [4–7]. Here, we report the case of a Belgian man who presented in Brussels with the typical association of endogenous endophthalmitis and K. pneumoniae septicemia secondary to a hepatic abscess, in a diabetes mellitus setting.
Case report
A 33-year-old man with history of poorly controlled insulin-dependent diabetes was admitted with a 1-week history of fever and right upper quadrant pain. He had already been treated with amoxycillin-clavulanate. The patient, a Belgian of Moroccan origin, has never travelled to Asia. On admission, body temperature was 36.7°C and there was a right upper quadrant abdominal tenderness. Laboratory studies disclosed the following values: haemoglobin, 12.8 g/dl; white blood cells count, 13,600/mm3 and a blood glucose level of 234 mg/dl. An abdominal computed tomography scan showed a low density lesion in the right lobe of the liver suggestive of liver abscess (Fig. 1). These findings led to the diagnosis of pyogenic liver abscess for which drainage was performed. Pus samples and blood cultures were positive for K.pneumoniae resistant to ampicillin and sensitive to other commonly used antibiotics. The patient was treated with levofloxacin 500 mg IV 12 h and ornidazole 1 g orally per day. On day 4 after admission, an ophthalmic examination was perfomed as the patient complained of a painful and red right eye with decreased vision. The best corrected visual acuity was 5/10 in the right eye and 8/10 in the left. A slit lamp examination revealed cells in the right eye anterior chamber, posterior synechiae, an important vitritis, the fundus was barely visible. A diagnosis of endogenous endophthalmitis was made and an intravitreal injection of ceftazidime 2.25 mg was administered associated with topical ceftazidime (50 mg/ml) hourly as well as prednisolone acetate 1% four times daily and atropine 1% twice daily. A strain of K. pneumoniae was sent to the department of microbiology at National Taiwan University College of Medicine, where it was proven to be serotype K1 and positive for mucoviscosity-associated gene A (magA) (Fig. 2). On day 11, the visual acuity in the right eye was still 5/10 while slit lamp examination demonstrated reduced anterior chamber activity as well as reduction of vitritis. Visualisation of the fundus was better and revealed a background retinopathy. On day 12, the patient suddenly insisted on being discharged. He was discharged with levofloxacin 500 mg p.o 12 h, prednisolone acetate 1% 6 h and a mixture of short and medium-acting insulin. On day 30, the patient came for a control and the situation was stabilized. A longer follow-up was impossible since the patient never came back.
Discussion
Endogenous endophthalmitis is an infectious process involving intra-ocular tissue. It is caused by haematogenous spread of pathogens in patients with septicemia. Most cases of endogenous endophthalmitis are due to fungal infection and gram positive bacteremia in patients with immunosuppression, diabetes, indwelling intravenous catheter or intravenous drug abusers [3, 8].
Community-acquired K. pneumoniae septicemia, associated with liver abscess and frequently complicated with endophthalmitis, has been a recurrent disease in Taiwan [1–3]. This condition is frequently associated with diabetes, which is considered as the most important predisposing factor [9]. In 2002, Fung et al. revealed that K. pneumoniae serotype K1 (capsular antigen) was significantly associated with liver abscess and endophthalmitis [1]. Recently, Fang et al. have identified a novel virulence gene in K. pneumoniae strains causing primary liver abscess [10]. Typically, these strains are characterized by the formation of elongated mucoviscous strings when a loop is passed through a colony. Hence the gene was named mucoviscosity-associated gene (magA). Furthermore, the K. pneumonia strain which carries the MagA gene is highly resistant to human serum and phagocytosis killing, suggesting an increased pathogenicity and virulence. Our strain of K. pneumoniae was serotype K1 and positive for MagA.
This report suggests that, rather than being confined to Taiwan, K. pneumoniae liver abscess complicated with endophthalmitis is becoming a global problem. In order to make a precise diagnosis and provide adequate therapy in cases of endogenous endophthalmitis, the combined effort of the internist, the microbiologist and the ophthalmologist is definitely required.
References
Fung CP, Chang FY, Lee SC, Hu BS, Kuo BIT, Liu CY, Ho M, Siu LK (2002) A global emerging disease of K. pneumoniae liver abscess: is serotype K1 an important factor for complicated endophthalmitis? Gut 50:420–424
Lee CC, Chen CY, Chen FH, Zimmerman RA, Hsiao HS (1998) Septic metastatic endophthalmitis from K.pneumoniae liver abscess: CT and MR imaging charasteritics-report of three cases. Radiology 207:411–416
Chen YJ, Kuo HK, Wu PC, Kuo ML, Tsai HH, Liu CC, Chen CH (2004) A 10-year comparison of endogenous endophthalmitis outcomes: an East Asian experience with K. pneumoniae infection. Retina 24:383–390
Cahill M, Chang B, Murray A (2000) Bilateral endogenous bacterial endophthalmitis associated with pyogenic hepatic abscess. Br J Ophthalmol 84:1436
Harris EW, D’Amico DJ, Bhisitkul R, Priebe GP, Peterson R (2000) Bacterial subretinal abscess: a case report and review of the literature. Am J Ophthalmol 129:778–785
Saccente M (1999) Klebsiella pneumoniae liver abscess, endophthalmitis, and meningitis in a man with recognized diabetes mellitus. Clin Infec Dis 29:1570–1571
Cobo MF, Aliaga ML, Diaz MF (1999) Liver abscess caused by Klebsiella pneumoniae in diabetic patients. Rev Clin Esp 199:517–519
Schiedler V, Scott IU, Flynn JR, Davis JL, Benz MS, Miller D (2004) Culture-proven endogenous endophthalmitis: clinical features outcomes. Am J Ophthalmol 137:725–731
Wang JH, Liu YC, Lee SSJ, Yen MY, Chen YS, Wang JH, Wann SR, Lin HH (1998) Primary liver abscess due to K. pneumoniae in Taiwan. Clin Infec Dis 26:1434–1438
Fang CT, Chuang YP, Shun CT, Chang SC, Wang JT (2004) A novel virulence gene in K. pneumoniae strains causing primary liver abscess and septic metastatic complications. J Exp Med 199:697–705
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Karama, E.M., Willermain, F., Janssens, X. et al. Endogenous endophthalmitis complicating Klebsiella pneumoniae liver abscess in Europe: case report. Int Ophthalmol 28, 111–113 (2008). https://doi.org/10.1007/s10792-007-9111-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10792-007-9111-4