If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
A 38-year-old male with cystic fibrosis (CF) with pancreatic insufficiency underwent a lung transplant for end-stage bronchiectasis. Before transplant, his respiratory tract had been colonized with Pseudomonas aeruginosa (Table 1, isolate 1). Over the course of his disease, he had been treated with broad-spectrum antibiotics for lower respiratory infections in the years before transplant (Table 1, isolates 2 and 3). Post-transplant, he was started on intravenous (IV) meropenem and colistin for empiric coverage.
Table 1Microbiological Characteristics of Pseudomonas aeruginosa Isolated from the Patient
Specimen
Isolate 1 Sputum (Colonizer 1 y Before Transplant)
Isolate 2 Sputum (2 mo Before Transplant, After Admission for LRTI)
His immediate postoperative course was complicated by a hemothorax requiring repeated thoracotomy to achieve hemostasis. His intensive care unit course was further complicated by the discovery of a left homonymous hemianopsia, left hemiparesis, and right lateral rectus palsy with sensory deficits secondary to a reperfusion injury. Magnetic resonance imaging of the brain confirmed anterior and middle cerebral territory infarcts. His electrocardiogram, carotid Doppler studies, and an echocardiogram were unremarkable. Blood cultures did not grow any organism. Fortunately, he stabilized and was discharged to a stroke rehabilitation facility. His immunosuppressive regimen consisted of mycophenolate mofiteil, tacrolimus, and prednisone.
While still at the stroke facility, the patient was referred to the ophthalmology service with a 3-day history of an infected right eye with mild pain and reduced visual acuity (VA). Upon presentation VA of the right eye was 20/80 with 2+ cells in the anterior chamber and 3+ conjunctival injection. The left eye was uninvolved. At presentation the posterior pole was reported as unremarkable, without any choroidal elevation. After assessment, he was diagnosed with nongranulomatous anterior uveitis and was treated with prednisolone drops every hour, maxidex ointment at night, and homatropine bid. Despite this therapy, his intraocular inflammation continued to worsen. Oral prednisone was added and a subtenon kenalog injection was performed. After these measures failed to improve the inflammation, he was referred to a retina specialist 12 days after his initial symptom onset.
At that time of referral, his VA was 20/400 OD. Slit lamp examination revealed 3+ cells in his anterior chamber with keratic precipitates. Examination showed vitreous debris and 3–4+ vitrits. Peripheral retinal examination displayed dense pale areas of retinal elevation with choroidal thickening in the temporal quadrants. B-scan ultrasonography confirmed the presence of choroidal thickening with a heterogeneous elevation in the subretinal space with a shallow retinal detachment at 9ON (Fig. 1, Fig. 2). Because of the patient’s significant immunosuppression and progression of intraocular inflammation with anti-inflammatory treatment, endogenous endophthalmitis was deemed to be the diagnosis. As a result, anterior and posterior chamber taps were performed for culture and intravitreal ceftazidime, vancomycin, and amphotericin B were injected.
Fig. 1B-scan of OD at presentation at 8 o’clock—heterogeneous subretinal mass with choroidal thickening, vitritis, and shallow retinal detachment.
The patient was started on vancomycin, piperacillin/tazobactam, ciprofloxacin, and voriconazole along with topical moxifloxacin eye drops under the guidance of the infectious diseases service. An aspirate of the vitreous tap was sent for culture and grew 1 isolated colony of methicillin-resistant Staphylococcus aureus on day 4. However, it was thought to be a lab contaminant. At that time blood cultures were negative. Chest x-ray was unremarkable. Computed tomography of the head and sinuses showed changes consistent with chronic inflammatory changes in the sinuses similar to a previous study. IV linezolid was subsequently added.
Two days later, the patient continued to worsen with further reduction in vision and increasing pain in his right eye despite intensive systemic (and the previous intravitreal) antibiotic therapy. Vision had decreased to hand motions. Clinical examination and ultrasound imaging revealed rapid expansion of the choroidal thickening. Cytological analysis of the vitreous fluid did not demonstrate evidence of malignancy.
Because of the obliteration of the vitreous cavity by the expansile choroidal mass, a pars plana vitrectomy could not be safely performed. As a result, external trans-scleral drainage of the choroidal mass was performed in the operating room. Purulent material was expressed from the scleral cut down, which was directly sampled for culture, and intravitreal injection of antibiotics into the residual vitreous cavity was repeated. The antibiogram sensitivity profile of the scleral cut down isolate resembled the isolate in broncho-alveolar lavage at the time of transplant (Table 1, isolate 4).
The purulent material from the choroidal drainage grew multidrug-resistant P. aeruginosa (Table 1, isolate 5). The patients’ antibiotics were switched to IV colistin, tobramycin, and vancomycin. Unfortunately, after an additional 2 weeks of aggressive antibiotic therapy, the patient experienced further visual loss, increased pain, and elevated intraocular pressure with appositional choroidal thickening. Surgical evisceration was required for infection and pain control. After the evisceration the patient did not experience any orbital extension of the infection.
P. aeruginosa colonization of the respiratory tract is common in CF populations with bronchiectasis.
This infection is usually confined to episodes of lower respiratory infections due to bio-film formation; however, bacteremia with disseminated infection may cause endogenous endophthalmitis.
A choroidal abscess secondary to P. aeruginosa after lung transplantation is a rare complication with only a small number of previous cases reported in the literature (Table 2).
The majority had undergone lung transplant and had underlying CF. Two of the cases required enucleation, 1 required cryopexy for retinal detachment, and the other had a severe retinal detachment with proliferative vitreoretinopathy requiring silicone oil.
From this small number of cases, the literature suggests that early diagnosis and treatment is the optimal way to preserve vision and avoid enucleation or evisceration. However, the complexity of presentation often makes diagnosis challenging, and as much as 29%–33% of cases have a delayed diagnosis.
The sensitivity profile of the Pseudomonas isolate in the present case reflects the progressive development of antibiotic resistance in this previously colonized strain and the likely dissemination of this infection at or just after the time of transplant. This is consistent with previous studies that have shown that systemic antibiotics are rarely capable of totally eradicating P. aeruginosa and explains the high degree of resistance found in these remaining organisms.
Although bronchiectasis and CF provide the right conditions for continued survival of P. aeruginosa species within the lungs, previous authors have suggested risk factors for hematologic metastatic spread to the choroid are bronchial instrumentation such as bronchoscopy or lung transplant surgery in this case.
In light of this evidence, ophthalmologists should continue to place a high index of suspicion and treat these patients aggressively to limit subretinal invasion and abscess formation.
00407-X&id=gr1.jpg){kind=link}
00407-X&id=gr2.jpg){kind=link}