A 28-year-old male presented to the emergency room (ER) with pain and redness in the right eye over the last 5 days. He was otherwise healthy and gave a past history of appendicectomy. His ocular history revealed laser refractive surgery procedure in both eyes 6 months prior to his presentation in another institution in Jordan. His history also revealed prior recent admission to a local hospital where he was found to have a high intraocular pressure of 50 mmHg which was managed by antiglaucoma medications: Latanoprost (Xalatan by Allergan) drops. He also received fortified antibiotics and topical steroids. No exact details of his treatment were available at the time of his presentation to our ER facility. He presented with vision of hand motion in the affected eye and intraocular pressure of 18 mmHg. His slit lamp examination of the right eye revealed severe conjunctival congestion with ciliary injection, opaque hazy cornea, and deep anterior chamber (AC) with 3 mm of dark pigmented hypopyon. There was no localized corneal infiltrate, but ring deep corneal dense haze was noticed possibly representing the edges of a previous laser-assisted in situ keratomileusis (LASIK) flap [Figure 1a and b]. There was no further view of the posterior cavity. The left eye examination was within normal limits.
The patient was admitted as a case of uveitis. His initial B-scan showed very mild vitreous opacity and no RC layer thickening, therefore was not considered to be typical of endophthalmitis [Figure 1c]. However, he was continued on fortified antibiotic drops (vancomycin 25 mg/ml and ceftazidime 50 mg/ml every 3 h around the clock, OD) and topical steroids: Prednisolone (Predforte by Allergan) drops four times/day, OD.
His differential diagnosis included post-refractive herpetic keratouveitis and masquerade syndrome. He was started on valtrex 500 mg twice daily, orally, in addition to the moxifloxacin 400 mg orally once daily. He was also kept on antiglaucoma medication: Combination of dorzolamide and timolol (Xolomol by Jamjoom Pharma) drops twice daily, OD.
His repeated B scans over 4 days following admission revealed increasingly dense organized vitreous opacities and significant retina and choroid (RC) layer thickening suggestive of early endophthalmitis [Figure 1d] for which AC washout, vitreous tap and intravitreal antibiotics were given in the form of vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and cefuroxime 1 mg/0.1 ml. Meanwhile his systemic investigations were within normal limits. His human immunodeficiency virus (HIV) testing, urine, and blood cultures were negative. His chest X-ray was clear.
The smears prepared from his AC washout showed necrotic debris insterspersed with both extra- and intracellular melanin granules. Moderate number of polymorphonuclear leukocytes were also present [Figure 2a]. The Grocott's methenamine silver (GMS), gram, and acid-fast stains were all negative. No malignant cells were seen to suggest a masquerade syndrome. The AC aqueous was sent for polymerase chain reaction (PCR) to rule out infectious etiology including herpetic infection, cytomegalovirus, varicella zoster, tuberculosis, and Chlamydia which were all negative. The aqueous fluid culture proved bacterial growth identified as Listeria monocytogenes in the blood agar plate [Figure 2b] and brain heart infusion (BHI) broth. The organism was sensitive to gentamicin and penicillin G. The culture of the vitreous fluid showed few gram positive bacilli which were not further identified. Valtrex and moxifloxacin were stopped and the patient was given intravenous penicillin G 15 million units every 6 h (following a negative skin test) for 2 weeks and then shifted to oral augmentin 1 g twice daily for another 2 weeks.
The patient subsequently developed cataract for which he underwent phacoemulsification with posterior chamber intraocular lens (PC-IOL) implantation 4 weeks after his admission [Figure 2c]. Another AC fluid was sent for culture at the time of his cataract procedure which was negative. His last examination 1 month following surgery showed vision of 2/200 in the right eye which improves with pinhole to 20/160 and intraocular pressure (IOP) 12 mmHg controlled on a single antiglaucoma medication (Xolamol drops). The slit lamp examination showed corneal + 2 edema and haze, total peripheral anterior synechia with shallow AC, stable IOL, and hazy fundus view [Figure 2d].