九州大学学術情報リポジトリKyushu University Institutional Repository

Endophthalmitis with Klebsiella PneumoniaeLiver Abscess

Dohmen, KazufumiClinical Research Center, National Nagasaki Medical Center

Okubo, HideoInternal Medicine, Okabe Hospital

Okabe, HironaoAnesthesiology, Okabe Hospital | Internal Medicine, Okabe Hospital

Ishibashi, HiromiClinical Research Center, National Nagasaki Medical Center

https://doi.org/10.15017/18682

出版情報：福岡醫學雜誌. 94 (2), pp.31-36, 2003-02-25. 福岡医学会バージョン：権利関係：

Fukuoka Acta Med. 94( 2) : 31-36, 2003 31

症 　 　 　 　例

Endophthalmitis with Klebsiella Pneumoniae Liver Abscess

Kazufumi DOHMEN*, Hideo OKUBO** Hironao OKABE* *'* * *, and Hiromi ISHIBASHI*

* Clinical Research Center, National Nagasaki Medical Center, Nagasaki 856-8562 Japan, and** Internal Medicine, * * *

Anesthesiology, Okabe Hospital, Fukuoka 811-2122 Japan

Abstract Endogenous endophthalmitis is a rare, but devastating complication of se-

pticemia. The prognosis of maintaining visual acuity in patients with septic endophthal-mitis is poor in spite of an early diagnosis and the timely start of conventional therapeutic

procedures because the intravitreous drug concentration remains low after the systemic administration of antibiotics due to the blood-ocular barrier. We treated an elderly female patient with endogenous endophthalmitis complicated with disseminated intravas-cular coagulation associated with a Klebsiella pneumoniae liver abscess. Endophthalmitis developed rapidly and we thus had to perform an enucleation of both eyeballs even though we made an early diagnosis and performed liver abscess drainage as well as the prompt systemic and subconjunctival administration of antibiotics. Our experience in treating this case emphasizes the need to perform the timely intravitreous infusion of antibiotics with a support therapy consisting of the systemic and subconjunctival administration of antibiotics for endogenous endophthalmitis associated with a Klebsiella pneumoniae liver abscess.

Key words : Endophthalmitis, Liver abscess, Klebsiella pneumoniae

Introduction

Endophthalmitis is an inflammatory proc-

ess involving the ocular tissue confined

inside the globes. Today endogenous endo-

phthalmitis is a rare complication of se-

pticemia thanks to the advent of antibiotics

which has now made the effective control of

sepsis possible. However, septic metastatic

endophthalmitis associated with eodocar-

ditis, pneumoniae, meningitis, pyelone-

phritis, urinary tract infection, prostatic and

abdominal surgery or a liver abscess, has

recently been recognized in immunocom-

promized patients or drug abusers")").

Bilateral endophthalmitis occurs in one

quarter of all such reported cases"). Sev-

eral reports have claimed that endogenous

endophthalmitis associated with a Klebsiella

pneumoniae liver abscess tended to result in

either a loss of vision or left patients with

only limited vision3>4)9) -11> The outcome is

believed to be dependent on how early the

treatment is initiated in addition to the

nature of the infecting organism. How-

ever, an extremely poor visual outcome is

generally unavoidable in spite of aggressive

treatment with the appropriate systemic

and subconjunctivally administration of

antibiotics. We treated an elderly female

with septic endophthalmitis and a Klebsiella

pneumoniae liver abscess who demonstrated

an enucleation of both eyeballs in spite of

the prompt administration of systemic anti-

32 K. Dohmen et al.

biotic therapy and liver abscess drainage.

Case report

An acutely ill 91-year-old Japanese

female patient was admitted with a 5-day history of a high fever and anorexia. She

had no significant medical history and had

been apparently healthy without medication until this episode. On emergent admission

her temperature was 36.1 °C and blood

pressure was 94/56 mmHg. Her face and extremities looked pale. Her conjunctiva

were neither anemic nor icteric. A physi-cal examination of the abdomen revealed an

enlarged tender liver, but no signs of per-itoneal irritation. The hemoglobin concen-

tration was 13.7 g/dl, the white blood cell

counts were 25,600/,u1 with a differential of bands 4 %, segmented 86 %, monocytes 6

and lymphocyte 4 %, and platelet counts 56 x 103/,u 1. The erythrocyte sedimentation

rate was 21 mm/hr and C-reactive protein

(CRP) 37.5 mg/dl. The blood sugar and hemoglobin A1C levels were normal at 115

mg/dl and 4.7 %, respectively. The he-

patic function profiles showed the total bilirubin to be 1.6 mg/dl, aspartate

aminotransferase 259 IU/l, alanine aminotransferase 310 IU/1, lactate dehy-

drogenase 759 IU/1, and alkaline phos-

phatase 189 IU/1. The blood urea nitrogen and creatinine levels were 53.4 mg/dl and 3.

0 mg/di, respectively. The prothrombin activity was 83.0 %, fibrinogen 454 mg/dl

and fibrinogen degradation product 10 ,ug/ ml. Abdominal ultrasonography (US)

revealed a hypoechoic mass with a central

high echogeneity and an irregular margin, measuring approximately 5 cm in the

greatest dimension in the antero-inferior to lateral segment of the liver (Figure 1). Computed tomography (CT) revealed a

mass with an inhomogenously decreased

Fig. 1 Ultrasonography revealed a hypoe-

choic mass with a central high

echogeneity and an irregular margin,

measuring approximately 5 cm in the

greatest dimension in the antero-infe-rior to lateral segment in the liver.

attenuation in the same area. These find-

ings showed the patient to be in a state of

disseminated intravascular coagulation

(DIC) associated with a pyogenic liver abs-

cess.

On day 1 Cefozopran (CZOP 2 g/day), Clindamycin (CLDM 600 mg/day) and

Gabexate mesilate (100 mg/day) were ad-ministered intravenously. On day 2 US-

guided percutaneous abscess drainage was performed. Approximately 30 ml of mucinous exudate including pus and blood

was drained. The cultures of fluid thus

obtained and the blood grew Klebsiella

pneumoniae. On day 3 bilateral exophthal-mos developed and the patient complained

of orbital pain. A CT examination, how-ever, showed no remarkably abnormal find-

ings in either the cranial region or eyeballs

(Figure 2). On day 4 a purulent exudate was recognized in both orbitaes. Levoflox-

acin ointment was administered and eye cooling was started. Klebsiella pneumoniae

was isolated from the exudate of the or-bitaes. Based on these findings, Klebsiella

Endophthalmitis with liver abscess

pneumoniae-caused endophthalmitis was

diagnosed. However, the patient's visual

acuity thereafter deteriorated rapidly even

though the fever went down and both the

liver function and DIC improved. The

visual acuity of both eyes was eventually

completely lost several days after the onset

of orbital pain. During ophthalmologic

examinations, the cornea and anterior

chamber of both eyes were found to be

extremely opaque, therefore a thorough

ophthalmologic examination could not been

performed. A visceral enucleation of the

both eyeballs ultimately had to be perfor-

med because of a possible infectious focus to

the surrounding tissues or organs and also

for cosmetic reasons (Figure 2).

Discussion

A pyogenic liver abscess is an emergent

disease frequently associated with a com-

promised host in such diseases as diabetes

33

mellitus and acquired immunodeficiency

syndrome etc. Klebsiella pneumoniae, a

highly virulent intraocular pathogen, is

most frequently isolated from the aspirate

of liver abscesses and blood in such patients.

Endophthalmitis is an inflammation of the

ocular tissue which is confined inside the

ocular globes. Therefore, the patient's

visual acuity rapidly worsens. Endogenous

eodophthalmitis is much less frequent than

exogenous eodophthalmitis. The associa-

tion of endogenous eodophthalmitis with a

Klebsiella pneumoniae liver abscess has been

reported by several authors')4)7)-11)13) In

our case Klebsiella pneumoniae was cultured

from blood, the exudates of liver abscess

and vitreous exudates. Though only a

small amount of vitreous aspirate is gener-

ally obtained in cases of endophthalmitis, a

culture of vitreous aspirate is an important

examination for establishing the diagnosis

and initiating prompt therapy because en-

Fig. 2 Computed tomography showed no remarkably abnormal findings in the cranial region, eyeballs or muscles in the orbitas (left). An enucleatio bulbi of both eyes was

performed (right).

34 K. Dohmen et al.

dogenous endophthalmitis frequently takes

a poor clinical course. Cheng et al

mentioned that of the 14 reported patients

with endophthalmitis associated with a

pyogenic liver abscess, 11 patients ended up

with a total loss of vision while two patients

had severely limited vision4).

The intravitreous injection of antibiotics

without delay seems to be an effective treat-

ment for endogenous endophthalmitis2>14>.

On the other hand, even patients who

promptly receive the intraveneous adminis-

tration of antibiotics and antibiotics oint-

ment for eyes still tend to demonstrate poor

results. This is because an inadequate

amount of the antibiotic is able to penetrate

into the vitreous humor after either subcon-

junctival or systemic administration. The

parenteral administration of most antibi-

otics does not consistently achieve adequate

intraocular bacterial inhibitory levels

because of the blood-retinal barrier. As a

result, the intravitreal injection of antibi-

otics with or without a vitrectomy has been

recommended1)9). Regarding treatment

with corticosteroids6), the efficacy of cor-

ticosteroids in the treatment of endogenous

endophthalmitis remains unknown, how-

ever, animal experiments have shown good

results with either corticosteroids or the

combined use of antibiotics and corticoster-

oids2)8d. In addition, the time interval

between the infection and the initiation of

intravitreous treatment is considered to be

an important factor. The treatment in

such cases should be initiated by the time

the vitreous becomes filled with the abscess

and the retina becomes inflamed. Two

articles noted that therapy for the treatment

of endophthalmitis initiated 12 hours after

infection of the microorganism was not as

effective as such therapy which was started

four to six hours after infection8".

Clinically, Chou et al demonstrated that a

delayed initiation of the treatment of more than two days for endogenous endophthal-

mitis resulted in blindness either in one or both eye balls5). They thus emphasized

that prompt therapy with intravitreous injections within 24 hours following the

diagnosis could possibly avoid blindness and

they also suggested that either cefamezin

plus gentamicin, vancomycin plus amikacin or vancomycin plus amikacin should obtain

a good response to Klebsiella pneumoniae endogenous endophthalmitis5).

The risk factors for septic metastatic

lesions associated with pyogenic liver abs-

cess have been reported to be a Klebsiella

pneumoniae abscess, bacteremia and the underlying diabetes mellitus by comparison

of patients with a pyogenic liver abscess who developed septic metastatic lesions

with those who did not4). Furthermore, as for the important factors for complicated

endophthalmitis in cases of Klebsiella

pneumoniae liver abscess, Fung et al demon-strated them to be serotype K1 of Klebsiella

pneumoniae serotypes and diabetes mellitus as the underlying disease). Among the 14

patients complicated with endophthalmitis of the 134 patients with Klebsiella

pneumoniae liver abscess ranging from 34 to 78 years of age in their report, 85.7 % (12 of

14) of the isolates belonged to serotype K1 and 92.3 % (13 of 14) were diabetic7.

There has so far been no paper reporting

advanced age to be an independent risk factor for endophthalmitis, however, physi-

cians now often encounter elderly patients with diabetes mellitus due to the overall

increase in the average lifespan. There-fore, as shown in our case, physicians should

be aware of the possible development of

septic endophthalmitis and should thus per-form prompt and aggressive treatment

Endophthalmitis with liver abscess 35

using a combined medical-ophthalmological

approach when even non-diabetic patients

develop Klebsiella pneumoniae liver abscess

and start to complain of ocular symptoms.

There is no clear evidence in the litera-

ture that the use of intravitreous injections

will improve the visual outcome in patients

with endophthalmitis. As a result, further

investigations regarding the optimal treat-

ment protocol are needed based on a large

population of endogenous endophthalmitis

patients in order to improve the prognosis of

this devastating infection.

1)

2)

3)

4)

5)

References

Barza M : Treatment of bacterial infec-tions of the eye, In Remington JS, Swartz MN (ed) : Current clinical topics in infec-tious diseases. 1st ed. pp. 158-194, McGraw-Hill International Book Co New York, 1980. Baum JL, Barza M, Lugar J et al.: The effect of corticosteroids in the treatment of experimental bacterial endophthal-mitis. Am J Ophthalmol 80: 513-517, 1975. Casanova C, Lorente JA, Carrillo F et al. : Klebsiella pneumoniae liver abscess as-sociated with septic endophthalmitis. Arch Intern Med 149 : 1467, 1989. Cheng D-L, Liu Y-C, Yen M-Y et al.: Septic metastatic lesions of pyogenic liver abscess. Their association with Klebsiella pneumoniae bacteremia in dia-betic patients. Arch Intern Med 151: 1557-1559, 1991. Chou F-F and Kou H-K : Endogenous endophthalmitis associated with pyogenic hepatic abscess. J Am Coll Surg 182 : 33-

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al.: Endophthalmitis therapy : Changing antibiotic sensitivity patterns and current therapeutic recommendations. Arch Ophthalmol 109 : 175-176, 1991. Fung C-P, Chang F-Y, Lee S-C et al.: A

global emerging disease of Klebsiella pneumoniae liver abscess : is serotype K1 an important factor for complicated endo-

phthalmitis? Gut 50 : 420-424, 2002. Furgiuele FP, Cameron JA, Sassani JW et al.: Treatment of Staphylococcus aureus endophthalmitis with tobramycin in a rabbit animal model. Ann Ophthalmol 12 : 1320-1325, 1980. Liao HR, Lee HW, Leu H-S et al.: En-dogenous Klebsiella pneumoniae endo-

phthalmitis in diabetic patients. Can J Ophthalmol 27 : 143-147, 1992. Liu Y-C, Cheng D-L and Lin C-L : Kleb- siella pneumoniae liver abscess associated with septic endophthalmitis. Arch Intern Med 146 : 1913-1916, 1986. Margo CE, Mames RN and Guy JR : Endogenous Klebsiella endophthalmitis. Report of two cases and review of the literature. Ophthalmology 101 : 1298-1301, 1994. Maylath FR and Leopold IH : Study of experimental intraocular infection. Am J Ophthalmol 40 : 86-101, 1955. Ohmori S, Shiraki K, Ito K et al.: Septic endophthalmitis and meningitis associat-ed with Klebsiella pneumoniae liver abs-cess. Hepatology Res 22 : 307-312, 2002. Talamo JH, D'Amico DJ and Kenyon KR : Intravitreal amikacin in the treat-ment of bacterial endophthalmitis. Arch Ophthalmol 104 : 1483-1485, 1986.

(Received for publication January 8, 2003)

36 K. Dohmen et al.

(和文抄録)

クレブシエラ肝膿瘍を合併 した転移性眼内炎症例

1)国立病院長崎医療セ ンター 臨床研究セ ンター

2)廣徳会 岡部病院内科

3)廣徳会岡部病院麻酔科

1)道 免 和 文,2)大 久保 英 雄,2)3)岡 部 廣 直,1)石 橋 大 海

　細菌性眼内炎は稀な疾患であるが,発 症 した際

には高頻度に敗血症 を伴 う.抗 生剤の静脈投与に

も拘わらず,血 液眼関門のために眼窩内への抗生

剤の移行の抵抗性が認められ,眼 科的予後は不良

とされている.わ れわれは肝膿瘍ならびに血管内

播種性凝固症候群(DIC)を 有した91歳 女性の細

菌性眼内炎例を経験 した.肝 膿瘍穿刺液培養,血

液培養のいずれからもKlebsiella　Pneumoniaeカ §

検出され,DICに 対する治療 と共に肝膿瘍 ドレ

ナージ,抗 生剤の静脈投与が開始された.治 療開

始3日 目より両眼痛が出現し,4日 目には眼球か

ら 膿 瘍 排 出 を 認 め た.膿 瘍 よ りKlebsiella

Pneumoniaeが 検 出され,　Klebsiella　Pneumoniae

を起炎菌 とした転移性細菌性眼内炎 と診 断 した.

眼内炎 は急速 に進行 し,眼 窩 内容摘出術 を施行 し

た.本 症例か ら細菌性眼 内炎 の早期発 見の重要性

と同時 に細 菌性 眼 内炎 に対 す る抗 生剤 の静脈 投

与 ・点眼投与 による治療抵抗性が あらためて示 さ

れ,本 疾患 に対 す る硝子体 内へ の抗生剤注入 をは

じめ とした積極 的かつ適切 な治療法の再考が必要

であ る.