Age and Ageing 2006 35(1):89-91; doi:10.1093/ageing/afj006
© The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
An unfamiliar course of a familiar illness: a rare ophthalmic complication of urinary sepsis
Charlie Wilkinson,
Ed Richfield and
Kate Rosenberg
The Department of Elderly Care, Beckett Wing, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
Address correspondence to: C. Wilkinson. Email: cpwilkinsonuk{at}yahoo.co.uk
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Abstract
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Uncommon complications may occur in the context of illnesses
encountered frequently in later life. They may be difficult
to both identify and manage in a drowsy, confused patient, particularly
in the absence of collateral information. We present an unusual
ocular complication in a patient with systemic sepsis from a
urinary tract infection, an unquestionably common diagnosis
in older patients admitted to hospital.
Keywords: older people, endogenous endophthalmitis, urinary tract infection, elderly
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Case report
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An 81-year-old woman with long-standing type 2 diabetes mellitus,
mild cognitive impairment and deafness was admitted having become
bedridden, confused and verbally non-communicative over a 24
h period. She had several witnessed rigors but did not exhibit
focal urinary, respiratory or gastrointestinal symptoms. She
was drowsy, febrile, and a mild bilateral conjunctival inflammation
with scleral injection was noted. She did not engage ocular
movements to auditory or visual cues, interpreted as confusion
related. A soft ejection systolic murmur and scattered right
basal chest crackles were present. Cataracts obscured retinal
views. Haemoglobin was 10.9 g/dl, white cells 24.3
x10.9/l with
neutrophilia and pO
2 on air was 8.1 kPa; otherwise, initial
investigations were unremarkable. She was given intravenous
saline, cefuroxime, chloramphenicol eye drops and an insulin
sliding scale. The pupils became fixed in mid-dilated position,
and a right-sided hypopyon developed. The red reflex was lost,
and no pupillary response to light or topical 1% tropicamide
was observed. Pus began to exude from the left eye, and a tense
bilateral periorbital cellulitis developed, which fused the
eyelids shut (Figure
1). Cranial computed tomography (CT) was
done (Figure
2).
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Figure 2.. Inflammatory changes behind the left globe and a relatively unenhancing left superior ophthalmic vein compared with the right.
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Contrast-enhanced CT showed left orbital proptosis, preseptal swelling, a thrombosed left superior ophthalmic vein (Figure 2) and an unequal enhancement of the left cavernous sinus, suggestive of thrombosis. Blood and urine culture grew Klebsiella terrigena, sensitive to ciprofloxacin, cephradine, gentamicin, piperacillin/tazobactam and meropenem. The eye swab was culture negative. She was treated with unfractionated heparin, intravenous ciprofloxacin, topical ofloxacin, atropine drops and intravitreal gentamicin. Over the next 5 days, she deteriorated and subsequently died.
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Discussion
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Endophthalmitis is the presence of replicating organisms, associated
with inflammation, within the eye [
1]. Subtypes include postoperative,
bleb-related (implanted filter for glaucoma), post-traumatic,
endogenous, and infection by immediate spread [
2]. Endogenous
(metastatic) endophthalmitis (EE) accounts for just 2–8%
of all infectious types and results from intraocular tissue
invasion by organisms arising from an extraocular source [
3,
4]. Despite its recognition since 1856, visual impairment still
results in up to 75% of cases [
3]. Predisposing conditions include
endocarditis, diabetes mellitus, immunocompromised states, indwelling
intravenous catheters, invasive surgery, gastrointestinal procedures,
malignancy, alcoholism and intravenous drug abuse [
5–7].
The urinary and biliary tracts, intra-abdominal abscesses, pneumonia
and meningitis are recognised sources [
5]. Symptoms include
reduced vision, eye pain, photophobia and floaters [
7,
8]. Findings
include reduced visual acuity, vitreitis, conjunctivitis, iritis,
retinitis, hypopyon (pus in the anterior chamber) and retinal
detachment [
6]. Although successful culture has been reported
from urine, wound swabs, intraocular and cerebrospinal fluid,
blood culture remains a high-yield investigation [
5,
7,
8].
While Gram-positive organisms account for the majority of postoperative endophthalmitis, Gram-negative bacteria account for up to 29% in EE and are associated with gastrointestinal and urinary infection [5, 8, 9]. Gram-negative EE is more frequently reported in East Asia: Klebsiella pneumoniae was the most frequently isolated pathogen in two case series from Singapore [10] and Taiwan [11]. Bilateral involvement is often seen with meningococcus, Escherichia coli and Klebsiella species [5]. The association of Klebsiella species with suppurative liver disease and diabetes is well documented [4, 11, 12]. Klebsiella endophthalmitis is associated with poor visual outcome and may require enucleation [9, 12, 13]. The cornerstone of treatment is prompt diagnosis and early intensive intravenous high-dose antibiotic therapy. Subconjunctival or subtenon antibiotic administration may be considered, but evidence for its additional benefit is lacking [3]. If progressive deterioration occurs, intravitreal administration is indicated.
In our case of metastatic bilateral Klebsiella panophthalmitis secondary to urinary sepsis, many features are consistent with previous descriptions [5, 11, 13]. Early concern regarding visual impairment was difficult to evaluate in an acutely ill and drowsy patient. The assumption that failure to engage ocular movement was due to confusion proved incorrect, and collateral information regarding eyesight would have been helpful. The vague presentation lacked specific features to implicate urinary sepsis, and importantly, early signs of ophthalmic involvement were misinterpreted as concomitant conjunctivitis. This case highlights the need for clinicians to be vigilant for the appearance of ophthalmic symptoms and signs in a septic patient. Urgent attention and early specialist involvement is needed should they develop.
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Key points
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- Unusual complications of common illnesses affecting older people should be entertained if atypical features occur.
- Assessing visual function in confused unwell older adults is difficult and should be revisited at an early stage with the aid of collateral information.
- Eye symptoms and signs in a patient with septicaemia should be dealt with as a potential ophthalmic emergency, with specialist input required at an early stage.
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References
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Received May 28, 2005; accepted in revised form August 14, 2005.
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Abstract
Case report