REFERENCES 1. Meyers SM. The incidence of fundus lesions in septicemia. Am J Ophthalmol 1979;88:661-667. 2. Neudorfer M, Barnea Y, Geyer O, Siegman-Igra Y. Retinal lesions in septicemia. Am J Ophthalmol 1993;116:728-734. 3. Silverberg HH. Roth's spots. Mt Sinai J Med 1970;37:77-79. 4. Kennedy JE, Wise GN. Clinicopathological correlation of retinal lesions in subacute bacterial endocarditis. Arch Oph thalmol 1965;74:658. 5. Schneider G. Roth's septic retinitis. Klin Monatsbl Augenheilkd 1984;184:225-226.
Candida tropicalis Multifocal Endophthalmitis as the Only Initial Manifestation of Pacemaker Endocarditis Haim Shmuely, MD, Israel Kremer, MD, Alex Sagie, MD, and Silvio Pitlik, MD PURPOSE: To document a case of Candida tropicalis endophthalmitis as the only manifestation of pacemaker endocarditis. METHODS: We examined a 75-year-old man with diabetes mellitus who was initially examined for bilateral multifocal endophthalmitis complicating endocarditis 2 years after a permanent pacemaker for sick sinus syndrome was implanted. RESULTS: Transesophageal echocardiography showed a large vegetation with a 3-cm diameter at tached to the pacing electrode in the right ventricle. Six consecutive blood cultures grew C tropicalis. CONCLUSIONS: Ocular involvement, including multifocal endophthalmitis, may occur as the only manifestation of C tropicalis endocarditis, compli cating an intravenous permanent pacemaker.
C
ANDIDA SPECIES ARE COMMON CAUSES OF DISSEMI-
nated disease in drug abusers, in severely ill hospitalized patients, and in those patients who are immunocompromised.1 Candida species are the fourth most common cause of nosocomial bloodAccepted for publication Nov 18, 1996. Departments of Internal Medicine "C" and Infectious Disease Unit (H.S., S.P.), Ophthalmology (I.K.), and Cardiology (A.S.), Rabin Medical Center, Sackler School of Medicine, Tel Aviv University. Inquiries to Haim Shmuely, MD, Department of Internal Medicine "C," Rabin Medical Center, Beilinson Campus, 49100 Petach Tikvah, Israel; fax: 972-3-922-1605; e-mail:
[email protected]
VOL.123, No. 4
stream infections.2 Despite the species' prevalence, Candida endophthalmitis is rare in patients with candidemia. In a recent multicenter trial,3 none of the 118 patients with candidemia showed evidence of endophthalmitis. We describe a patient with C tropi calis multifocal endophthalmitis as the only initial symptom of pacemaker Candida endocarditis. A 75-year-old man with a 10-year history of diabetes mellitus was admitted to the hospital because of recent bilateral visual blur. Visual acuity was BE, 20/40—. The anterior segment was unremarkable except for moderate (+2) nuclear sclerosis bilaterally. Ophthalmoscopic examination of both eyes (Figure) disclosed several white retinal lesions, 0.2 to 0.8 disk diameter, with snowball-like exudation in the adja cent cortical vitreous and a mild vitreous haze, consistent with the diagnosis of bilateral multifocal endophthalmitis. According to his history, our patient had had a permanent pacemaker implanted 2 years before ad mission because of recurrent attacks of syncope that were related to sick sinus syndrome. Transesophageal echocardiography showed a large vegetation measur ing 3 cm in diameter attached to the pacemaker lead wire just below the tricuspid valve, within the right ventricle. Six consecutive blood cultures grew C tropicalis. There were no other systemic manifesta tions of candidemia. Computed tomography of the brain and lumbar puncture were normal, and a test for human immunodeficiency virus was negative. Intravenous therapy with amphotericin B in com bination with flucytosine was immediately instituted. The patient refused open-heart surgery to remove the infected electrode. Nonsurgical removal of the elec trode was infeasible because of the high risk of embolization. Despite the continuation of antifungal therapy, the patient's septic condition deteriorated, and in the third week of hospitalization, he died of multiorgan failure. Pacemaker-related Candida infection is extremely rare. In most reported cases, the diagnosis of fungal endocarditis was made at the postmortem examina tion.4 This case shows that even without other symptomatology for candidemia, visual disturbances in patients with permanent pacemakers may be alarming signs of this life-threatening septic compli cation. Despite the absence of systemic signs and
BRIEF REPORTS
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Endogenous Ochrobactrum anthropi Endophthalmitis Adrienne J. Berman, MD, Lucian V. Del Priore, MD, PhD, and C. Kenneth Fischer, MD
Figure. A fundus photograph of the patient's left eye showing mild posterior vitreous haze and two white retinal lesions, of 0.2 and 0.8 disk diameter, located inferior to the fovea, with snowball-like exudation in the adjacent vitreous.
symptoms of fungemia in a patient with unilateral or bilateral retinal a n d vitreous lesions, as with our patient, a thorough examination including trans-
esophageal echocardiography and multiple blood and urinary cultures should be performed to diagnose fungus endocarditis and to initiate intensive systemic antifungal therapy. When a pacemaker becomes infected and the patient is unresponsive to therapy, the physician should consider removing the pacemak er either by extrapolation or open-heart surgery.5 REFERENCES
PURPOSE: To describe bilateral endogenous en dophthalmitis caused by Ochrobactrum anthropi in a partially immunosuppressed patient who had undergone central venous access for hyperalimentation and home intravenous therapy. METHODS: Case report. RESULTS: Blood cultures were positive for O anthropi. Vitreous cultures grew a gram-variable bacillus. The patient's ocular and systemic condi tion markedly improved after intravitreal antibiotics and systemic ciprofloxacin. CONCLUSIONS: Ochrobactrum anthropi may cause endogenous endophthalmitis in patients with a history of indwelling catheters for venous access or other permanent medical devices.
A
74-YEAR-OLD WOMAN EXPERIENCED 2 WEEKS OF
visual loss in her left eye. She had undergone cataract extraction with posterior chamber lens im plants in both eyes 4 years previously. Medical history included osteoporosis with vertebral, pubic, and hip fractures; polymyalgia rheumatica requiring chronic prednisone; and prior lumbar laminectomy. Four months previously, she had undergone placement of an indwelling catheter for epidural morphine infusion for chronic lower back pain; subsequently, she devel oped aspiration pneumonia that was treated with intravenous clindamycin and oral clarithromycin. She developed signs and symptoms of bowel obstruction and underwent emergency laparotomy that disclosed pseudomembranous colitis. A central line was placed for hyperalimentation, and treatment with intrave-
1. Uliss AE, Walsh JB. Candida endophthalmitis. Ophthalmolo gy 1983;90:1378-1379. 2. Banerjee SN, Emori TG, Culver DH. Secular trends in nosocomial primary bloodstream infections in the United States 1980-1989. National Infections Surveillance System. AmJ Med 1991;91(3B,suppl):86S-89S. 3. Donahue SP, Greven CM, Zuravleff JJ, et al. Intraocular candidiasis in patients with candidemia. Ophthalmology 1994;101:1302-1309. 4. Parkers JC. The potentially lethal problem of cardiac candidosis. Am J Clin Pathol 1980;73:356-361. 5. Parry G, Goudevenos J, Jameson S, Adams PC, Gold RG. Complications associated with retained pacemaker lead. Pac ing Clin Electrophysiol 1991;8:1251-1257.
Accepted for publication Nov 13, 1996. Barnes Retina Institute and the Departments of Ophthalmology and Visual Sciences (A.J.B., L.V.D.) and Biochemistry and Molecular Bio physics (L.V.D.), Washington University School of Medicine; private practice, Evansville, Indiana (C.K.F.). Supported in part by an unrestrict ed grant from Research to Prevent Blindness, Inc, New York, New York. Inquiries to Lucian V. Del Priore, MD, PhD, Department of Ophthal mology and Visual Sciences, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8096, St Louis, MO 63110; fax: (314) 362-3725; e-mail:
[email protected]
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OPHTHALMOLOGY
AMERICAN JOURNAL
APRIL 1997
