A 16-year-old girl presented with pain, redness, watering, and blurred vision in her right eye for 4 days. There was no history of ocular trauma, surgery, or contact lens use. She had a history of fever 15 days before this episode associated with burning micturition, papulomacular rash over the lower abdomen and groin, and vague joint pains for which she took symptomatic treatment elsewhere (no previous records available). Currently, the patient was using topical antifungals and antibiotics in the right eye for the past 2 days.
On examination, her best-corrected visual acuity (BCVA) was hand movements close to the face in the right eye and 20/20 in the left eye. A slit-lamp examination of the right eye showed intense circumcorneal congestion and a ring-shaped corneal infiltrate with an epithelial defect measuring around 6 mm x 6 mm. The anterior chamber was quiet with no hypopyon and the lens was phakic [Figure 1a]. Fundus examination revealed hazy media due to corneal involvement with a disc hazily seen and a retina attached. The left eye appeared normal. Corneal sensations were intact in both eyes. Corneal scrapings were obtained and sent for microbiological analysis. Gram stain of corneal scrapings revealed Gram-negative rods and culture yielded heavy growth of K. pneumoniae [Figure 2] later identified as ESBL producers by VITEK (automated method for antibiotic sensitivity testing). Antibiotic susceptibility testing determined by agar disk diffusion (Kirby-Bauer method) showed that the isolates were sensitive to amikacin, gentamicin, tobramycin, tigecycline, and trimethoprim-sulfamethoxazole. The patient was started on fortified amikacin (2.5%) and fortified tobramycin (1.3%) hourly with cycloplegic drops in the right eye.
In view of the recent history of fever with rash and joint pains, pediatric consultation was sought to rule out a systemic cause for corneal ulcer which could be autoimmune or infective. Her blood investigations included a complete blood count with an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), random blood sugar along with blood culture, Mantoux test, and chest X-ray. HLA B27, rheumatoid factor, and antinuclear antibody were done to rule out any autoimmune cause. Ultrasound abdomen and pelvis were done to look for any septic foci which came out to be normal. Investigations revealed leukocytosis, raised ESR (102 mm), CRP (26.1 mg/dL), and blood culture with confluent growth of K. pneumonia after 24 h of incubation. Rest investigations were negative. Hence, a probability of endogenous Klebsiella keratitis in the right eye was considered, although the exact source of the primary infection could not be detected. The patient was admitted and started on intravenous antibiotics gentamicin and piperacillin with tazobactam based on the blood culture sensitivity report.
After 1 week of treatment, the patient's systemic symptoms resolved. Ocular examination showed a resolving corneal infiltrate with no epithelial defect and BCVA improved to 20/200 in the right eye [Figure 1b]. The patient was discharged and was kept on follow-up. One week later, she reported to us with redness and watering in her left eye. On examination, her BCVA was 20/40 in both eyes. Slit-lamp examination showed a scarring ring infiltrate in the right eye with mild corneal edema [Figure 1c]. There was a paracentral stromal infiltrate measuring 2 mm x 2 mm with no epithelial defect, quiet AC, and no hypopyon in the left eye [Figure 1g]. Corneal scraping was deferred in view of the small infiltrate size (<=2 mm) and no epithelial defect. The patient was started on the same fortified antibiotics considering the likelihood of Klebsiella keratitis in this eye as well.
One week later, the patient came for a follow-up which revealed scarred infiltrate in the right eye [Figure 1d] and diffuse stromal edema, granulomatous keratic precipitates (KPs), and 3+ cells in AC in the left eye [Figure 1h]. The patient was investigated thoroughly to rule out uveitis due to any other pathology (tuberculosis, sarcoidosis, and syphilis) which came out to be negative. She was started on topical steroids six times a day along with antibiotics and cycloplegic drops keeping a possibility of immune-mediated pathology in the left eye. A diagnosis of healed endogenous Klebsiella keratitis in the right eye with immune-mediated keratouveitis in the left eye was made.
On the 2-week follow-up, her BCVA improved to 20/20 in both eyes with scarred infiltrate and quiet AC bilaterally [Figure 1d and i]. Her fundus examination was normal on all the visits [Figure 3].
The patient was doing well when 4 months later; she again had a similar episode of uveitis in the right eye [Figure 1e]. This was preceded by a fever for 1 day which resolved on symptomatic treatment. There were no other systemic features. Blood investigations were negative. Hence, a possibility of recurrent uveitis secondary to endogenous infection was kept and was successfully treated with a short course of topical steroids [Figure 1f]. The patient is on follow-up for the past 6 months and maintains a BCVA of 20/20 OU with normal intraocular pressure and quiet AC.