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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 152-155

Loss of both eyes from endogenous endophthalmitis in a term neonate with pseudomonas sepsis


1 Department of Paediatrics, Federal Medical Centre, Katsina, Nigeria
2 Department of Opththalmology, Federal Medical Centre, Katsina, Nigeria

Date of Submission23-Oct-2019
Date of Decision22-Nov-2019
Date of Acceptance26-Jan-2020
Date of Web Publication21-Apr-2020

Correspondence Address:
Dr. Abubakar Sani Lugga
Department of Paediatrics, Federal Medical Centre, Katsina
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_114_19

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  Abstract 


Pseudomonas aeruginosa sepsis is associated with high morbidity and mortality in the neonatal period. It is the most common cause of endogenous endophthalmitis which is a rare ophthalmic emergency that can result in complete blindness. Diagnosis can be a challenge in the neonate, hence the need for early ophthalmic consultation in babies presenting with fever, eye swelling, and discharge. Early diagnosis and prompt appropriate treatment are very important to prevent death and disability. This case report demonstrates the rapid progression of endogenous endophthalmitis due to Pseudomonas sepsis, which resulted in the loss of both eyes within a few days of onset.

Keywords: Corneal perforation, endogenous endophthalmitis, Pseudomonas aeruginosa


How to cite this article:
Lugga AS, Ibrahim N, Ibrahim AO, Paret SG. Loss of both eyes from endogenous endophthalmitis in a term neonate with pseudomonas sepsis. J Clin Neonatol 2020;9:152-5

How to cite this URL:
Lugga AS, Ibrahim N, Ibrahim AO, Paret SG. Loss of both eyes from endogenous endophthalmitis in a term neonate with pseudomonas sepsis. J Clin Neonatol [serial online] 2020 [cited 2020 Dec 3];9:152-5. Available from: https://www.jcnonweb.com/text.asp?2020/9/2/152/283023




  Introduction Top


Endophthalmitis refers to infection of the inner coats of the eye associated with progressive vitreous inflammation.[1] It is rare in the neonates but poses more life-threatening complications. Endogenous endophthalmitis arises from the hematogenous seeding of microorganisms into the eye from a distant focus of infection, whereas exogenous endophthalmitis results from direct inoculation of microorganisms from outside.[1],[2],[3] Exogenous endophthalmitis is more common and can be a complication of ocular surgery, retained intraocular foreign bodies, or penetrating ocular trauma. Endogenous endophthalmitis accounts only for 2%–8% of all cases of endophthalmitis, with the retina, choroid, and the ciliary body being the primary sites of infection because of their higher blood supply.[3] Being a rare complication of neonatal sepsis, endogenous endophthalmitis is often misdiagnosed as conjunctivitis.[4]

Pseudomonas aeruginosa is the most common cause of neonatal endophthalmitis.[2] By virtue of its very high virulence, it can have a fulminant course, rapidly progressing from conjunctivitis to perforating keratitis and to endophthalmitis within 72 h of onset.[2] Therefore, there is the need for a high index of suspicion, early eye swab, and blood culture for the diagnosis as well as treatment with broad-spectrum systemic and topical antibiotics to prevent death or blindness.

P. aeruginosa has a predilection for preterm babies.[5] Here, we present the case report of a 5-day-old term neonate who lost both eyes from endogenous endophthalmitis due to Pseudomonas sepsis. This case report is presented in order to alert clinicians to the serious problem of neonatal sepsis due to P. aeruginosa and its potential to lead to blindness.


  Case Report Top


A 5-day-old female neonate was referred from a primary health-care facility to our special care baby unit with fever, swelling of both eyes, and eye discharge which all started 1 day before the presentation. She had purulent discharge from both eyes which became bloody few hours before presentation. She was delivered at term by spontaneous vaginal delivery to a 22-year-old primiparous woman in a primary health-care facility. The pregnancy was supervised, and the mother had fever toward the time of delivery but had no other symptoms of infection. No prolonged rupture of membranes and no features of asphyxia at birth. There was no history of trauma or the application of traditional medications to the eyes. Umbilical cord care was with traditional hot compress.

She was irritable and febrile with axillary temperature of 40°C. She had tachycardia with a pulse rate of 188 beats/min and low peripheral oxygen saturation of 88% breathing room air. She had marked edema of both eyelids with bloody purulent discharge; however, further examination of the eyes was limited by the presence of marked palpebral edema. Her weight at presentation was 2200 g although her birth weight was not known.

The diagnosis was neonatal sepsis with ophthalmia neonatorum. Intravenous ceftriaxone, intravenous gentamycin, and topical chloramphenicol were commenced empirically after the samples have been taken for blood culture and swabs from both eyes. Supplemental oxygen therapy was also commenced immediately. Full blood count showed leukocytosis, with a left shift of neutrophils and toxic granulation on blood film.

The baby developed severe eyelid edema on the 2nd day of admission which warranted ophthalmology consultation. The ophthalmologist reported marked lid edema, proptosis, and chemosis in both eyes and made a diagnosis of bilateral orbital cellulitis. On the 5th day of admission, the blood culture result was gotten which yielded P. aeruginosa. Based on the sensitivity pattern, ceftriaxone, gentamycin, and chloramphenicol were continued, and topical ofloxacin was added every 2 h. Cultures from both eye swabs and urine were all negative. On the same day, the eyelid edema had reduced remarkably, and proper ophthalmic examination was carried out which revealed bilateral proptosis and ophthalmoplegia, anterior chamber inflammation, absent red reflex, hazy vitreous with exudates and poor view of the fundus on the right eye, and exposed cornea on the left. A diagnosis of bilateral endophthalmitis with left corneal perforation was made, and topical ofloxacin and chloramphenicol were applied copiously and more frequently (hourly) into both eyes to keep them lubricated, and the left eye was covered with an eye pad [Figure 1]. Topical dexamethasone was also commenced. By the 8th day, the right cornea was sclerosed and the left cornea was eroded with uveal prolapse [Figure 2]. Orbital magnetic resonance imaging was planned but could not be done because of financial constraint.
Figure 1: The baby at the 5th day of admission with copious purulent discharge from the right eye and padding of the left eye following corneal perforation

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Figure 2: The baby on the 8th day of admission with perforated left cornea and uveal prolapse

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Antibiotics were continued for 21 days, and she was discharged following resolution of fever, eye discharge, and swelling. At the time of discharge, the parents were counseled about the child's condition that both eyes were already lost and were told about the options of prosthesis. Eye dressing was continued daily after discharge.

She is on follow-up at both the ophthalmology and the neonatology clinics. Now, at the age of 5 months, she has not achieved social smile, but has achieved neck control and sits with support. She has bilateral enophthalmos following auto-enucleation of the eyeballs [Figure 3]. The parents have been told about the cosmetic benefits of prosthesis and the options which include an acrylic ball insertion into the eyecup to restore orbital volume, but they are yet to decide whether to go for it or not.
Figure 3: The baby during follow-up at 5 months of age with complete blindness and enophthalmos

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  Discussion Top


Endophthalmitis can be classified as endogenous or exogenous, depending on the route of entry of infection. Endogenous endophthalmitis develops when eye infection occurs due to hematogenous spread of infection from distant sites.[2],[6] It is a rare complication of neonatal sepsis with P. aeruginosa being the most common organism isolated.[2]

Most cases of neonatal Pseudomonas endophthalmitis are nosocomial in origin with only a few reported cases in nonoutbreak settings.[7],[8] However, the baby described in this report presented with sepsis already, and the infection was most likely community acquired. The source of infection could have been the maternal genital tract, although there was no history to suggest overt infection in the mother except fever in the last 2 weeks of pregnancy. It could also be from umbilical cord care which was done with traditional hot compress. The birth environment (a primary health care facility) could have also been the source, although details of the hygiene of the facility as well as the level of practice of asepsis by the staff were not gotten.

The first symptom is purulent eye discharge in more than 80% of cases.[2] Other common symptoms include fever, eyelid swelling, and redness. This baby presented with fever, purulent eye discharge and eyelid swelling. The eye discharge in this baby was bloody, a finding that is rare in Pseudomonas conjunctivitis but common in chlamydia conjunctivitis. In fact, hemorrhagic eye discharge is a highly specific sign of neonatal chlamydial conjunctivitis and has been reported to have a specificity of 100% and positive predictive value of 100% for chlamydial infection.[9]

P. aeruginosa is very virulent and exerts its effect by producing proteoglycanolytic enzymes, endotoxins, and exotoxins, leading to the breakdown of tissues including corneal stroma and conjunctival blood vessels.[2],[5] This leads to a fulminant course of inflammation with orbital cellulitis, endophthalmitis, panophthalmitis, and eventually corneal perforation. This baby had this fulminant course, as she progressed from sepsis with conjunctivitis on the day of admission to bilateral endophthalmitis and left corneal perforation within 5 days of admission. She had features of orbital cellulitis on the 2nd day of admission, but proper ophthalmic examination to diagnose endophthalmitis was not done until the 5th day (6 days after onset of symptoms). Previous reports have shown that endophthalmitis is diagnosed on average 5 days after the onset of conjunctivitis.[2]

Blood culture was positive for P. aeruginosa, whereas cultures from the eye swabs from both eyes were negative. Blood culture has been reported to be positive in more than 90% of cases, whereas vitreous cultures are positive in only 56%.[2] Conjunctival swabs are not reliable for the diagnosis because of several physiological conjunctival flora which are often replaced by nosocomial flora.[2]

The predisposing factors to neonatal endophthalmitis include low gestational age, low birth weight, babies requiring aggressive resuscitation at birth, padding of the eyes during phototherapy, antenatal maternal vaginal discharge, prolonged rupture of amniotic membranes, low social class, low maternal education, lack of antenatal care attendance, maternal age <20 years, and place of delivery.[3],[10] Among these, only low social class and low maternal education were identified in this patient.

P. aeruginosa sepsis is more common among preterm infants. In a tertiary hospital in India, all six neonates with Pseudomonas endophthalmitis over 3 years were preterm.[3] Similarly, all four reported cases of Pseudomonas endophthalmitis in Birmingham were preterm.[8] The mean gestational ages for neonatal Pseudomonas endophthalmitis in the United States, Australia, Turkey, and the United Kingdom were 27.4, 25.5, 31, and 26 weeks, respectively.[7] The baby described in this report is, however, a full-term neonate.

Early use of systemic antibiotics is the mainstay of treatment for endophthalmitis. Some authorities recommend the use of a combination of intravenous cephalosporin and aminoglycoside as the most appropriate treatment for endophthalmitis.[8] This baby received a third-generation cephalosporin (ceftriaxone) and an aminoglycoside (gentamycin) which were both commenced as empiric treatment and continued when the blood culture result showed a strong sensitivity to both antibiotics. Topical antibiotics were also used in this patient, although a combination of topical and systemic antibiotics has not been proven to be superior to systemic antibiotics alone. Topical antibiotics have poor penetration into the anterior chamber and vitreous humor, hence have limited usefulness in endophthalmitis.[2]

Our patient also received topical steroid (dexamethasone) even though there are limited data on the use of steroids in endophthalmitis, and the results of studies are conflicting.[1] The use of adjunctive corticosteroid therapy is particularly controversial for P. aeruginosa corneal ulcers.[11] Corticosteroids have been shown to reduce the host inflammatory response, thus protecting the cornea, but they may also significantly slow the process of corneal wound healing, prolong infection, and predispose to stromal thinning and perforation.[11]

Morbidity and mortality in Pseudomonas endophthalmitis are high despite early diagnosis and treatment.[5],[8] The baby described in this report has lost both eyes. Blindness of the affected eye(s) is common among survivors.[12] She had perforation of the left cornea with uveal prolapse, a finding which has been reported in cases of Pseudomonas endogenous endophthalmitis in other case reports.[3]

At the time of writing this case report, the infant is 5 months old. She has achieved age-appropriate gross motor developmental milestones, but has not achieved social smile likely because of loss of vision.


  Conclusion Top


Neonatal sepsis due to P. aeruginosa is associated with high morbidity and mortality. Survivors of Pseudomonas endogenous endophthalmitis usually have severe visual impairments and in most cases complete loss of the affected eye(s). In view of this fact, we emphasize the importance of daily examination of the eyes as a part of routine clinical care in neonates with sepsis for early diagnosis and prompt treatment of endophthalmitis. An early ophthalmology consultation will limit morbidity and optimize the outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the child's images and other clinical information to be reported in the journal. The patient's parents understand that the child's name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. Endogenous endophthalmitis: Diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect 2015;5:32.  Back to cited text no. 1
    
2.
Lloyd LG, Witt W. The mystery of the disappearing eye: A neonatal case report. SAJCH 2014;8:34-6.  Back to cited text no. 2
    
3.
Basu S, Kumar A, Kapoor K, Bagri NK, Chandra A. Neonatal endogenous endophthalmitis: A report of six cases. Pediatrics 2013;131:e1292-7.  Back to cited text no. 3
    
4.
Murugan G, Shah PK, Narendran V. Clinical profile and outcomes of pediatric endogenous endophthalmitis: A report of 11 cases from South India. World J Clin Pediatr 2016;5:370-3.  Back to cited text no. 4
    
5.
Shah SS, Gloor P, Gallagher PG. Bacteremia, meningitis, and brain abscesses in a hospitalized infant: Complications of Pseudomonas aeruginosa conjunctivitis. J Perinatol 1999;19:462-5.  Back to cited text no. 5
    
6.
Gaili H, Woodruff GH. Exogenous Pseudomonas endophthalmitis: A cause of lens enucleation. Arch Dis Child Fetal Neonatal Ed 2002;86:F204-6.  Back to cited text no. 6
    
7.
Harnaen E, Doctor TN, Malhotra A. Characteristics of Pseudomonas aeruginosa infection in a tertiary neonatal unit. Int J Padiatr Res 2015;1:2-5.  Back to cited text no. 7
    
8.
Boyle EM, Ainsworth JR, Levin AV, Campbell AN, Watkinson M. Ophthalmic Pseudomonas infection in infancy. Arch Dis Child Fetal Neonatal Ed 2001;85:F139-40.  Back to cited text no. 8
    
9.
Chang K, Cheng VY, Kwong NS. Neonatal haemorrhagic conjunctivitis: A specific sign of chlamydial infection. Hong Kong Med J 2006;12:27-32.  Back to cited text no. 9
    
10.
Mohammed A, Ibrahim M, Mustafa A, Ihesiulor U. Maternal risk factors for neonatal conjunctivitis in Aminu Kano Teaching Hospital, Kano, Nigeria. Niger J Basic Clin Sci 2013;10:50-5.  Back to cited text no. 10
    
11.
Sy A, Srinivasan M, Mascarenhas J, Lalitha P, Rajaraman R, Ravindran M, et al. Pseudomonas aeruginosa keratitis: Outcomes and response to corticosteroid treatment. Invest Ophthalmol Vis Sci 2012;53:267-72.  Back to cited text no. 11
    
12.
Kearney FM, Maccheron LJ, Gole GA. Loss of an eye in a baby from keratitis initially managed as conjunctivitis. Med J Aust 2006;185:515-6.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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