Endogenous Clostridium perfringens Panophthalmitis with Potential Entry Port from Diverticulitis Exacerbated by Proliferative Diabetic Retinopathy

Case Reports in Ophthalmological Medicine
15 Apr, 2019 ,

A 61-year-old female with poorly controlled diabetes mellitus, active proliferative diabetic retinopathy, and recent diverticulitis presented with conjunctival injection, ocular discharge, and sudden onset of painful vision loss of the left eye. Patient denied history of ocular trauma, intraocular surgery, or intravenous drug abuse. Examination revealed an erythematous, proptotic eye with restricted extraocular movements, mucopurulent discharge, diffuse corneal edema, and vitreous haze and cell. Orbital computed tomography (CT) confirmed no retained intraocular foreign body.

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A 61-year-old female with poorly controlled diabetes mellitus with severe bilateral PDR presented to the emergency department at Upstate University Medical Center. Initially, the patient presented to an outside emergency room with conjunctival injection, copious purulent discharge and associated painful vision loss to no light perception (NLP) in the left eye. Patient was then transferred to Upstate University Medical Center for higher level care and was evaluated by the ophthalmology service 18 hours after symptom onset. She underwent lateral canthotomy and cantholysis at the outside hospital 6 hours prior to arrival, due to severe pain and concern for orbital compartment syndrome; however patient endorsed complete loss of vision 12 hours prior in her left eye. She had no ocular trauma or history of intravenous drug abuse.

However, she noted to have a two-month history of intermittent left abdominal pain and diarrhea, along with an abdominal computed tomography (CT) reporting diverticulitis. On presentation, examination revealed an edematous, erythematous, and proptotic left eye with severely restricted extraocular movements. The anterior segment exam revealed diffuse conjunctival injection, mucopurulent discharge from superotemporal globe, diffuse corneal edema and haze, and extensive fibrin in the anterior chamber. The dilated exam was limited due to corneal edema, diffuse anterior chamber reaction, and dense vitritis. Ophthalmic ultrasonography revealed a subluxed lens with diffuse vitritis. Orbital CT confirmed no retained intraocular foreign body or occult penetrating injury.

Upon admission, patient's blood and specimens from ocular mucopurulent discharge were sent for gram stain and culture. The gram stain revealed gram-positive bacillus. The patient was admitted and started on intravenous (IV) broad spectrum antimicrobial therapy (vancomycin, meropenem, and amphotericin B). Due to progressive clinical decline with associated leukocytosis and encephalopathy 48 hours after initiating systemic antimicrobial treatment and gram stain results, she underwent enucleation of the left eye. Postoperatively, the patient completed a full course of IV vancomycin and meropenem.

Reflex anaerobic culture from the mucopurulent collection grew Clostridium perfringens and gross specimen from the enucleation revealed numerous gram-positive bacillus microbes. Anaerobic microbes seen on staining and samples were inoculated onto prereduced anaerobically sterilized Brucella blood agar, phenylethyl alcohol blood agar, kanamycin-vancomycin laked blood agar, and Bacteroides bile esculin agar (Oxyrase, Inc., Mansfield, OH). The inoculated plates were incubated at 35 degrees C anaerobically using the AnaeroPack-Anaero Anaerobic Gas Generator (Mitsubishi Gas Chemical America, New York, NY). After 48 hours of incubation, 2+ growth of a gram-positive bacillus was noted on the Brucella blood agar. These colonies were identified as Clostridium perfringens by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (Vitek MS, bioMerieux, Inc., Durham, NC). No other growth was observed.

Amphotericin B was discontinued once fungal etiology was excluded. Subsequently, both the periorbital edema and erythema resolved. Additionally, the patient regained consciousness, as her encephalopathy and infection improved. She was subsequently transferred to local rehabilitation facility. A repeat CT abdomen demonstrated the previous inflammation had resolved, likely due to the aggressive inpatient broad spectrum antibiotics. No comorbid occult distal gastrointestinal malignancies were found.