A case of Listeria monocytogenes endophthalmitis with recurrent inflammation and novel management
© Weber et al. 2015
Received: 13 August 2015
Accepted: 11 September 2015
Published: 5 October 2015
Listeria monocytogenes is a rare cause of endogenous endophthalmitis. In the limited number of reported Listeria endophthalmitis cases, visual acuity outcomes have been very poor.
Here, we report a case of Listeria endophthalmitis that was complicated by recurrent inflammation. The patient required treatment with both intravitreal and long-term systemic antibiotics. An anterior chamber washout was necessary for the patient to regain 20/20 visual acuity.
This case highlights the importance of considering Listeria early in the disease course, as it has low sensitivity to standard empiric antibiotic therapy. It also stresses the importance of addressing damaging inflammation in infectious conditions.
KeywordsListeria monocytogenes Bacterial endophthalmitis Recurrent inflammation Anterior chamber washout
Listeria monocytogenes is a gram-positive bacillus transmitted through contaminated food including unpasteurized dairy products, meats, seafood, and raw vegetables. It is typically associated with gastrointestinal illness and rarely affects the eye . The most common form of ocular listeriosis in adults is conjunctivitis, although keratitis, endophthalmitis, and chorioretinitis have also been described [2–5]. Listeria endogenous endophthalmitis has been described in both immunocompetent and immunocompromised patients [2, 6]. While there are few L. monocytogenes endophthalmitis cases in the literature, Jackson et al. isolated L. monocytogenes in 10 of 267 endogenous endophthalmitis cases .
L. monocytogenes endophthalmitis typically presents with eye pain, increased intraocular pressure (IOP), and a fibrinous anterior chamber reaction. Many cases develop an evolving dark hypopyon due to iris pigment dispersion . Most reports have final vision worse than 20/200, and only two reports document final visual acuity better than 20/60 [6, 9, 10]. We present a case of endogenous L. monocytogenes endophthalmitis in a healthy male who recovered 20/20 vision after aggressive intravitreal and systemic antibiotic therapy and anterior chamber washout. His follow-up course was complicated by recurrent inflammation. To our knowledge, this is the first reported case of Listeria endophthalmitis complicated by recurrent inflammation. This case highlights the importance of early diagnosis and treatment with consideration of early surgical intervention following antibiotic therapy to produce a better visual outcome.
A 58-year-old Caucasian man presented with increasing right eye redness and tearing for 2 days. The patient’s past medical history was significant for well-controlled type 2 diabetes mellitus. On initial clinical exam, visual acuity was 20/400 in the right eye and 20/20 in the left eye. His intraocular pressure was 51 mmHg in the right eye and 17 mmHg in the left eye. Slit-lamp examination of the right eye showed 3+ conjunctival injection, corneal edema, and a fibrinous reaction in the anterior chamber. His left eye exam was unremarkable.
Two days after his antibiotic course was completed, the patient presented with redness and right eye pain. Visual acuity was 20/40, intraocular pressure was 20 mmHg, and the patient had 2–3+ cells in the anterior chamber. Concerned for recurrence, an anterior chamber tap was performed, oral trimethoprim-sulfamethoxazole was restarted, and topical gentamicin and prednisolone acetate were increased to every 2 h. Three days later, 4+ anterior chamber cells were noted, and his intraocular pressure was 36 mmHg. He received an intravitreal injection of amikacin. Cultures from the repeat anterior chamber tap showed no growth, and universal bacterial Polymerase Chain Reaction (PCR) was negative.
Despite adequate antibiotic treatment, numerous case reports show poor visual acuity outcomes following L. monocytogenes endophthalmitis. Most patients have final vision worse than 20/100, and one case resulted in phthisis [2, 6, 8, 11–16]. As with all cases of endophthalmitis, prompt intravitreal antibiotics is the key factor for a good visual outcome . At our institution, bacterial endophthalmitis is empirically treated with intravitreal vancomycin and ceftazidime. However, L. monocytogenes has variable resistance to both of these agents.
Due to exceedingly rare prevalence of L. monocytogenes endophthalmitis, it is not high on most differentials, and diagnosis is made only after culture. This can delay proper antibiotic coverage, thereby allowing a sizeable inflammatory response to mount. Therefore, in the setting of a hypopyon—in particular a dark hypopyon—with high intraocular pressure, Listeria should be considered and appropriate antibiotics administered. Given Listeria endophthalmitis is most commonly endogenous, systemic antibiotics are an important complement to intravitreal antibiotics.
It is unclear if the patient’s recurrent episodes of inflammation represent repeated infection. Follow-up culture and universal PCR were negative suggesting this may be recurrent inflammation alone. Recurrences of systemic L. monocytogenes infections have been documented in adult patients, and recurrence of L. monocytogenes infections in the pediatric population has been linked to immune system deficiencies [17–21]. There have not been any previous reports of recurrent L. monocytogenes endophthalmitis in the literature.
In this patient, the majority of the inflammatory response was localized to the anterior chamber. After proper antibiotic therapy and oral steroids, the patient had a persistent, large, and dense hypopyon that was not resolving despite clearing of anterior chamber cells. In addition, the hypopyon was causing progressive corneal edema due to the presence of inflammatory mediators in the hypopyon. This led to the decision to pursue anterior chamber washout to prevent further corneal damage.
Ocampo et al. treated recalcitrant anterior segment inflammation in sarcoid uveitis patients with surgical removal of iris granulomas, applying similar logic used to justify vitrectomy in chronic uveitis. By removing immune cells and cytokines, one can halt the cycle of ongoing inflammation and prevent further damage to native structures . Our patient’s vision improved dramatically following anterior chamber washout, and the cornea cleared shortly thereafter. It is our observation from this case and review of the literature that when a robust inflammatory response persists after the initial infectious trigger has been adequately treated, surgical removal of the inflammatory milieu may be indicated.
This case exemplifies the importance of a wide differential diagnosis when approaching endophthalmitis. In endogenous cases, there is a range of potential culprit organisms, as in this case, that may not be responsive to empiric therapy . Patients should be followed closely until a therapeutic response is evident. Continued follow-up even after adequate treatment is equally important in order to promptly treat recurrent inflammation or infection.
The patient has given his consent for publication.
intraocular pressurePolymerase Chain Reaction (PCR)
None besides the authors listed.
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