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Dark hypopyon in Streptococcus bovis endogenous endophthalmitis: clinicopathologic correlations
© The Author(s) 2010
Received: 12 September 2010
Accepted: 3 October 2010
Published: 30 October 2010
The aim of this report is to present a previously unreported causative organism associated with brown-pigmented hypopyon in a patient with endophthalmitis.
This is a retrospective case report which includes clinicopathologic correlations.
Vitreous cultures demonstrated Streptococcus bovis infection resulting in a brown-pigmented hypopyon, with uveal pigment found intra- and extracellularly on pathologic examination of the pupillary membrane.
S. bovis endophthalmitis may be a cause of dark hypopyon, especially in patients with a history of liver disease, and, when identified, warrants colonoscopy and cardiac workup.
The presence of brown pigment within a hypopyon is a useful diagnostic clue and has been reported in the setting of necrotic intraocular melanoma as well as Listeria monocytogenes and Serratia marcescens endogenous endophthalmitis [1, 2].
We report a patient that presented with brown hypopyon in the setting of Streptococcus bovis endogenous endophthalmitis, thereby expanding the differential diagnosis for this clinical clue. This report also discusses the systemic associations, especially colon cancer and endocarditis .
Blood cultures were drawn and the patient was started on intravenous penicillin 3 million units/4 h and cefotaxime 1 gm/8 h for probable bacteremia. Abdominal ultrasound and CT showed evidence of cirrhosis, and transthoracic echocardiography was normal. Vitreous and blood cultures revealed S. bovis. The patient underwent colonoscopy, which ruled out colon cancer.
On day 19, the patient underwent repeat vitreous cultures and intravitreal injection of vancomycin and dexamethasone. Cultures were negative, however the final visual acuity was light perception and the eye developed significant iris heterochromia (Fig. 1c and d).
This report expands the causes of dark hypopyon to include S. bovis, a Gram (+) cocci occasionally isolated from the human digestive tract and known to cause endocarditis, and morez rarely, urinary infections and neonatal septicemia and meningitis. Although rarely associated with ocular infections, S. bovis has been reported in cases of endogenous endophthalmitis, although the authors did not comment on the color of the hypopyon .
An important association between S. bovis and colon cancer has been demonstrated, although the exact mechanism remains elusive . A change in colonic flora secondary to hepatic dysfunction was hypothesized to explain S. bovis translocating from the intestinal mucosa into the blood stream . Our patient had longstanding liver dysfunction, which likely contributed to his bacteremia; he did not, however, develop colon cancer during 4 years of follow up.
Pink hypopyon has been associated with both S. marcescens due to necrosis and bleeding and Klebsiella pneumonia due to red pigment prodigiosin [6, 7]. L. monocytogenes endophthalmitis presents with brown hypopyon, profound vision loss, and no identifiable extraocular focus of infection . In contrast to our patient, Listeria is associated with significant glaucoma, which, similar to the dark hypopyon, is ascribed to pigment dispersion. While our patient had normal IOP, pigment dispersion (Fig. 2) and eventual iris heterochromia (Fig. 1d) suggest a similar mechanism.
In summary, S. bovis endophthalmitis may present with brown hypopyon, and should be suspected in patients with a history of liver disease. Once S. bovis is cultured, colonoscopy and cardiac workup should be performed.
Supported in part by an unrestricted grant to the Department of Ophthalmology from Research to Prevent Blindness Inc., New York, NY; grant from the Fletcher Jones Foundation.
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