Acute painful vision loss and acute abdomen: a case of endogenous Clostridium perfringens endophthalmitis

Abstract

A 66-year-old woman with systemic lupus erythematosus treated with corticosteroids was admitted to hospital with anasarca due to protein-losing autoimmune enteropathy. Her past medical history included hypertension, hypothyroidism, cholecystectomy and resolved pneumococcal pneumonia. She was purportedly allergic to amoxicillin. Results of physical examination were remarkable for increasing abdominal girth and pitting edema to the level of her mid-abdomen. Laboratory studies revealed mild anemia (hemoglobin level 9.4 g/dL, hematocrit 28.9%), low levels of sodium (125 mmol/L) and albumin (1.0 g/dL), elevated erythrocyte sedimentation rate (116 mm/h), antinuclear antibody titre of 1:640 with a speckled pattern and rheumatoid factor level of 362 IU/mL. Results of cardiac, hepatic and renal evaluations were normal. During the admission, abdominal pain developed abruptly and painful vision loss developed over 12 hours in her right eye, to the level of hand motion. Bedside ophthalmic examination of this anxious and tachypneic patient’s right eye revealed palpebral edema, moderate conjunctival injection and a poorly dilated pupil. She had a clear cornea and a quiet anterior segment. Fundus examination disclosed moderate vitreous cellularity, inflammatory material precipitated on a detached posterior hyaloid and superior intraretinal hemorrhages. Findings in the left eye were normal. Endogenous endophthalmitis was diagnosed, and the patient’s blood and peritoneal fluid were sampled for microbiologic study. The patient urgently underwent vitreous tap and intravitreal injection of 1 mg of vancomycin (10 mg/mL) and 400 μg of amikacin (4 mg/mL) at the bedside. Although pars plana vitrectomy was considered, the patient’s systemic condition precluded operative intervention. The patient was promptly treated intravenously with clindamycin, vancomycin and ceftriaxone. One day later, a gas-forming clostridial organism was suspected when gram-positive rods were seen in the vitreous specimen, with bubbling of the inoculated broth. Polymicrobial spontaneous bacterial peritonitis was diagnosed when peritoneal fluid cultures yielded Streptococcus, Staphylococcus and Clostridium species. Clostridium was cultured from her blood as well. Later, the eye, peritoneal and blood cultures revealed the same organism, which ultimately was found to be C. perfringens. The patient immediately underwent intravitreal injection of 1 mg of clindamycin (10 mg/mL). Intravenously administered penicillin, considered the treatment of choice for C. perfringens infection when combined with clindamycin, was then added to her antimicrobial regimen. On the third day after the initial intravitreal antibiotic injection, the patient perceived light in the right eye. The cornea was cloudy, a hypopyon and fibrin were present in the anterior chamber, and the iris detail was reduced. The red reflex was absent, with no view to the retina owing to the inflammatory material filling the vitreous cavity. Later that day, the patient was overwhelmed by multiorgan failure and died shortly thereafter. The family declined an autopsy. From *the Casey Eye Institute, Oregon Health and Science University, Portland, Ore., the Departments of †Infectious Diseases and ‡Ophthalmology, Kaiser Permanente Northwest, Clackamas, Ore., and §the Department of Internal Medicine, Providence Portland Medical Center, Portland, Ore.