Bilateral sequential Propionibacterium acnes exogenous endophthalmitis
© Saffra et al. 2016
Received: 3 March 2015
Accepted: 16 May 2016
Published: 24 May 2016
A 68-year-old man underwent uncomplicated sequential cataract extractions performed more than a year apart. He presented 6 months after the second surgery with persistent intraocular inflammation in both eyes. Cultures from both eyes grew Propionibacterium acnes and he responded well to treatment. Suspicion for delayed-onset post-operative endophthalmitis must remain high in uveitis cases that fail to resolve with anti-inflammatory treatments. The authors believe this is the first reported case of bilateral sequential P. acnes exogenous endophthalmitis.
A 68-year-old main underwent uncomplicated cataract extraction with posterior-chamber intraocular lens (IOL) placement in his right eye in May 2009 and in his left eye in July 2010. Post-operatively, he was tapered off all topical anti-inflammatory medications. In February 2011, he presented with painless vision loss in the left eye and was noted to have marked anterior granulomatous uveitis with mutton-fat keratic precipitates and 3+ anterior chamber cells. Visual acuity at this time was 20/400. The vitreous and right eye examinations were unremarkable. On close follow up, he developed macular edema and optic disc leakage in the left eye. A medical workup by his internist and a rheumatologist, including testing for sarcoidosis, Lyme disease, syphilis, tuberculosis and HLA-B27 antigen were negative. He responded to topical steroids with subsequent improvement in his vision to 20/50. However, in November 2011, he again presented with painless vision loss in the left eye for one week. Acuity at this time was light perception and slit lamp exam reveal an inflamed eye with a 3.5-mm hypopyon. B scan ultrasonography demonstrated an attached retina with vitritis. The patient underwent immediate anterior and posterior tap and injection with ceftazidime and vancomycin followed by a pars plana vitrectomy (PPV) the following day. Aqueous cultures grew Propionibacterium acnes sensitive to clindamycin and moxifloxacin. The inflammation resolved following antibiotic treatment and vitrectomy. Final visual acuity was 20/40 and was limited by an epiretinal membrane.
Chronic post-operative endophthalmitis (CPE) is characterized as an infectious intraocular inflammation that occurs more than 6 weeks after ocular surgery—sometimes months to years later. It can mimic other types of ocular inflammation and may respond initially to corticosteroid treatment. Cases of chronic post-operative inflammation that fail to resolve with corticosteroids should elicit a high suspicion for CPE.
P. acnes is an anaerobic, gram-positive bacillus that is found as part of the normal flora of the skin, hair follicles and conjunctiva . It has been identified as the causative agent for various implant-associated infections and accounts for the majority of CPE cases . Formation of a posterior capsular plaque is the most classic finding of P. acnes CPE; however, it is not always present. The small number and low virulence of the organism often result in a low yield in microscopy and negative culture from anterior chamber (AC) taps. . Pars plana vitrectomy and/or polymerase chain reaction may improve detection in cases where a high suspicion is maintained despite negative AC cultures.
While bilateral P. acnes endogenous endophthalmitis presenting as scleritis and uveitis has been reported in a patient who did not undergo ocular surgery , we believe this is the first report of exogenous bilateral sequential P. acnes post-operative endophthalmitis. This case highlights the importance of maintaining a high suspicion of P. acnes endophthalmitis in a post-operative patient with chronic inflammation. PPV with IOL explantation, capsulectomy, and intravitreal antibiotics results in the lowest recurrence rate; however, this may not be necessary in all cases, and treatment should be tailored for each patient.
AC, anterior chamber; CPE, chronic post-operative endophthalmitis; IOL, intraocular lens; P. acnes; Propionibacterium acnes; PPV pars plana vitrectomy
All authors received no funding for this research.
NS and EM conducted the clinical management of the patient and prepared the manuscript. TM carried out the histopathologic studies. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Written informed consent was obtained from the patient for the publication of this report and the accompanying images.
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