Unique Presentation of Endogenous Klebsiella Endophthalmitis From a Pyogenic Hepatic Abscess

Abstract

The following is a rare presentation of endogenous klebsiella endophthalmitis associated with a pyogenic liver abscess. A 64-year-old Cantonese male presented to our tertiary care center with subjective fevers and left eye vision loss. His vision loss began four days prior to presentation and was associated with progressive pain, swelling, and redness of the same eye. Orbital CT with contrast confirmed presence of both periorbital and post-septal orbital cellulitis, as well as endophthalmitis. Infection was presumed to be from an endogenous source given the patient's fevers, so the patient was started on intravenous vancomycin, ceftazidime, and metronidazole. Blood cultures taken in the emergency room prior to the administration of antibiotics revealed no growth over the next five days. A CT abdomen/pelvis obtained to determine an infectious source revealed a 7 cm x 5 cm liver abscess. Interventional radiology biopsy of the abscess displayed infection with pan-susceptible Klebsiella pneumoniae. Antibiotics were de-escalated to intravenous ceftriaxone and ophthalmology recommended evisceration of the left eye. Six sets of blood cultures all remained negative for Klebsiella bacteremia throughout the patient's hospital course. Klebsiella endophthalmitis is a rare but devastating infection associated with pyogenic hepatic abscesses, particularly in Asian populations. Patients with hepatic abscesses causing systemic symptoms generally present with right upper quadrant pain and sepsis secondary to bacteremia before the onset of ocular symptoms. Our patient uniquely presented with initial symptoms of vision loss coinciding with onset of fevers and had negative blood cultures further complicating diagnosis. Treatment of endogenous endophthalmitis involves intravenous and intravitreal antibiotics, however, infection is rapidly progressive and often leads to permanent vision loss requiring enucleation or evisceration of the eye. Given the low incidence of ophthalmic disease in patients with pyogenic hepatic abscesses, there are no current guidelines for routine ophthalmology screening in the absence of visual symptoms. However, physicians should monitor patients with known liver pathology, particularly those of Asian descent, for complaints of ocular symptoms.