BMJ Case Reports | 2021
Sieve-like preretinal exudates in Stenotrophomonas maltophilia endogenous endophthalmitis
Abstract
© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 26yearold woman presented with symptoms of sudden diminution of vision in the left eye for 4 days. She also had pain and redness in her left eye. She was a primigravida and had a spontaneous abortion at 8 weeks’ gestation, which was managed by a gynaecologist with intravenous medications and fluids. Two weeks after the management of miscarriage, she developed ocular symptoms. On examination, the right eye was unremarkable with bestcorrected visual acuity (BCVA) 20/20. In the left eye, she had a perception of hand movements close to face with accurate light projection in all quadrants. On examination, she had lid oedema, conjunctival congestion, 3+ cells in the anterior chamber (AC), posterior synechiae, fibrin in the AC and vitreous exudates. Diagnosis of endogenous endophthalmitis (EE) was made; pars plana vitrectomy with vitreous biopsy was performed in the left eye, followed by injection of intravitreal antibiotics (vancomycin and ceftazidime) and dexamethasone. Intraoperatively, vasculitis along with preretinal, sievelike exudates, sparing the posterior pole, was observed. Urine and blood culture showed no growth. Growth of gramnegative bacilli was seen in vitreous culture. Gramnegative bacilli were identified as Stenotrophomonas maltophilia by the VITEK-2 system. The organism was observed to be sensitive to amikacin, ciprofloxacin, colistin and gentamycin while being resistant to imipenem, chloramphenicol and ceftazidime. Oral ciprofloxacin (750 mg two times per day for 1 week) was prescribed in the postoperative period. Intravitreal amikacin and dexamethasone were injected twice with an interval of 48 hours. In the postoperative period, preretinal exudates in a sievelike pattern were noted. The exudates resolved gradually (figure 1). At 8week followup, BCVA was 20/30 in the left eye, the AC was quiet and an early epiretinal membrane was noted with a few preretinal exudates in the midperiphery (figure 2). Endogenous endophthalmitis, a potential blinding ailment, occurs due to the hematogenous spread of microorganisms. The incidence of EE is lower than postsurgical and posttraumatic endophthalmitis. Predisposing factors include intravenous drug abuse, immunosuppression, the recent history of intravenous drug administration and prolonged intensive care. In Southeast Asia, gramnegative organisms are responsible for most EE cases. S. maltophilia (earlier known as Pseudomonas maltophilia and Xanthomonas maltophilia) is an aerobic, motile, nonfermenting, gramnegative rod. S. maltophilia infection can cause bacteraemia, pneumonia, urinary tract infection, endocarditis, meningitis, peritonitis and/or ocular infections. Other than EE, S. maltophilia is known to cause acute conjunctivitis, scleral buckle infections, Figure 1 (A) Fundus montage image of the left eye 1 week after surgery showing sievelike preretinal exudates inferiorly and nasally, multiple round preretinal scattered lesions are seen as well. Vitritis causing grade 3 vitreous haze is noted. (B) An enlarged image of (A) demonstrating sievelike exudates. Gradual resolution of vitreous haze and preretinal exudates were seen during postoperative week 2 (C) and week 4 (D).