Saturday, October 20, 2012

A rare case of endogenous Streptococcus group C endophthalmitis associated with cellulitis

A rare case of endogenous Streptococcus group C endophthalmitis associated with cellulitis

Sept 2011

Group C Streptococci are part of the human flora and rarely cause opportunistic infections. Here we report a case of endophthalmitis presumably caused by a cellulitis of the arm.
Case Report:
A 59-year-old woman with non-insulin-dependent diabetes mellitus had been given an influenza vaccination into her left arm with chronic lymph oedema. Two days later she developed painful swelling of the arm. Another 24 h later she noticed decreased visual acuity of the right eye and pain. On presentation, the patient was febrile and a cellulitis involving the entire left arm with marked swelling was present. Systemic therapy with penicillin 2.4 g every 4 h and flucloxacillin 1 g every 6 h had already been started. The visual acuity was hand movements. The cornea showed mild exposure keratopathy due to a lagophthalmos of 2 mm secondary to a pre-existing facial nerve palsy. The pupil was mid-dilated and non-reactive. A hypopyon was present and visualization of the posterior segment was not possible owing to dense vitritis. Vitreous and anterior chamber taps were done and ceftazidime (2.25 mg/0.1 ml) and vancomycin (1 mg/0.1 ml) were injected intravitreally. Gram staining of the aqueous tap featured Gram-positive cocci growing in chains, which were later identified as group C Streptococci. The B-scan showed an attached retina and dense vitreous debris. Blood cultures (taken after commencement of systemic antibiotics) did not grow any microorganisms. One day later the visual acuity further deteriorated to perception of light. Owing to corneal stromal opacity it was not possible to safely perform a vitrectomy. Topical prednisolone hourly and 50 mg oral prednisone were added to the antibiotic treatment. Despite three more intravitreal injections of antibiotics over the following 10 days there was no improvement. Surgery involving keratoprosthesis, lensectomy, and vitrectomy was now offered to the patient, who declined this approach. The eye eventually became phthisical.
Streptococcal endophthalmitis is exogenous in the vast majority of cases and is caused by organisms from the viridians group (50%), followed by Enterococcus (27%), Streptococcus pneumoniae (12.5%), and beta-haemolytic Streptococci (10.5%). Endogenous Streptococcalendophthalmitis is uncommon, and we could only find two case reports in which group C Streptococcus was the causative microorganism. Our case highlights the importance of early recognition and the poor prognosis of endogenous Streptococcal endophthalmitis.

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