Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis: the importance of early diagnosis and intervention

Clinical record

A 51-year-old man presented to the Royal Victorian Eye and Ear Hospital with 3 days of progressive visual loss and pain in the left eye, and a 6-hour history of painless visual loss in the right eye. He reported a 1-week history of fever, night sweats, sore throat and a non-productive cough. The man was systemically well, with no features of sepsis or abdominal pain.

His only medical history was for hypercholesterolaemia. He was Malaysian, but had lived in Australia for 10 years. He had recently travelled to Malaysia and Vietnam.

Visual acuity (VA) was hand movements in the left eye and 6/12 in the right. He had a left relative afferent pupillary defect and bilateral hypopyon. Vitritis limited posterior segment examination. The left eye had lid swelling, conjunctival chemosis, proptosis, and computed tomography (CT) showed evidence of scleritis (Figure, A).

White cell count (26 × 10⁹/L; reference interval [RI], 4.0–11.0 × 10⁹/L) and C-reactive protein levels (199 mg/L; RI <5 mg/L) were both elevated; liver function tests were deranged, with evidence of cholestasis. Liver ultrasonography revealed a 5.3 cm abscess in segment VII. A CT scan showed two abscesses: a 5.0 × 5.7 cm abscess in segments V/VIII and a 3.3 × 5.1 cm abscess in segment VII, with cholelithiasis and segmental thrombosis of the right hepatic vein (Figure, B). The results of blood cultures were negative.

VA in the right eye deteriorated to counting fingers over a 24-hour period, and endogenous Klebsiella pneumoniae endophthalmitis was suspected. The patient received systemic ceftriaxone; bilateral intravitreal vancomycin, ceftazidime and dexamethasone; and oral and topical corticosteroid therapy. K. pneumoniae was cultured from ultrasound-guided drainage of one liver abscess and from urine. Repeated vitreous samples included polymorphonuclear leukocytes, but no bacteria could be cultured. Hepatic vein thrombosis was treated with therapeutic enoxaparin and, later, rivaroxaban.

Pars plana vitrectomy (PPV) was performed in the right eye 2 days after presentation, and a superotemporal subretinal abscess was noted. Vision initially improved to 6/24, but deteriorated to hand movements 2 days after the operation, presumably following rupture of the abscess. A second PPV was performed, and the abscess was drained. A rhegmatogenous retinal detachment was managed intraoperatively with endolaser and silicone oil (Figure, C). The right eye received four doses and the left eye five doses of intravitreal vancomycin, ceftazidime and dexamethasone.

The left eye underwent a two-stage PPV, with the first surgery 4 days after presentation. An inferior subretinal abscess was drained during the second PPV (Figure, C and D). An associated rhegmatogenous retinal detachment was treated with endolaser and silicone oil.

Both eyes settled well (Figure, E and F). The retinae remained attached bilaterally under oil, and best-corrected VA had improved to 6/12 in the right eye and 6/24 in the left eye at the 1-month follow-up.

Endophthalmitis refers to inflammation of the intraocular space, and is predominantly of infectious aetiology. It is usually exogenous and may complicate intraocular surgery, penetrating trauma or corneal ulceration. Around 2%–8% of cases occur via endogenous spread, often in the context of immunosuppression, diabetes or injecting drug use.1

In Australia, fungal organisms cause 65.9% of endogenous endophthalmitis, while gram-negative organisms cause 19.5%.1 In East Asia, there is an increasing incidence of disease caused by gram-negative organisms, with Klebsiella pneumoniae now the most common cause of endogenous endophthalmitis.2–4 K. pneumoniae is a known cause of pyogenic liver abscess in southeast Asia, with metastatic spread of infection occurring in 3.5%–20% of cases and endogenous K. pneumoniae endophthalmitis (EKPE) in 3%–7.8% of cases.3

EKPE has an extremely poor prognosis.2–5 Retinal damage occurs rapidly following irreversible necrosis of the retinal photoreceptor layer and the associated subretinal abscess formation.1–7 Final visual outcomes of hand movements or worse are reported in 66%–78% of cases,3,7 no perception of light in 57.8%–62%,7,8 and evisceration or enucleation in 26.8%–75% of patients;1,8 in one report, three cases of EKPE required enucleation despite appropriate intensive antibiotic treatment.6

The poor prognosis is exacerbated by delayed diagnosis, particularly in patients who, because of overwhelming systemic illness, are unable to describe visual symptoms.2 Further significant predictors of a worse prognosis include poor initial visual acuity3 and the presence of hypopyon at presentation.8

In rare cases, EKPE may be the first manifestation of K. pneumoniae infection.3 EKPE is usually unilateral, but bilateral ocular involvement is reported in up to 26% of patients.1 Diabetes is a risk factor for EKPE.2,5 There is no general consensus about the most appropriate treatment for EKPE.

It has been suggested that pars plana vitrectomy (PPV) reduces intraocular bacterial and inflammatory load in EKPE and aids the penetration of intravitreal antibiotics.2,6 The best visual outcomes are seen in patients who undergo surgery early.4 In a Korean report about seven patients (10 eyes) with EKPE, early PPV was performed on eight eyes and delayed PPV on two. Operative findings included extensive retinal necrosis with subretinal abscess formation and dense vitritis. Five eyes maintained a final VA of counting fingers or better, VA in two eyes improved to 6/19 and 6/38; no enucleations or eviscerations were required.2 Another group described a patient who had PPV within 8 hours of the onset of EKPE symptoms; VA had improved from 6/120 to 6/6 at the 12-month follow-up.9 These results support the role of early PPV in the management of EKPE.

A series of five patients had previously been treated for EKPE at the Royal Victorian Eye and Ear Hospital. All were treated with intravenous and intravitreal antibiotics. Four of the five patients required enucleation or evisceration, and the fifth became phthisical. Our patient, the sixth case, presented early in the course of disease, and was treated with systemic and intravitreal antibiotics, as well as with early PPV. In contrast to the preceding cases, the visual outcome was excellent.

The incidence of K. pneumoniae liver abscess in the Asia-Pacific region is increasing. Early ophthalmology referral for patients with suspected or proven K. pneumoniae liver abscess is recommended. In patients with known EKPE, early PPV should be performed in conjunction with intensive systemic and repeated intravitreal antibiotic and steroid therapy to reduce intraocular bacterial and inflammatory load, and to aid the penetration of intravitreal antibiotics to the subretinal focus of infection. This may increase the chances for rescuing the eye and improving the visual outcome.

Lessons from practice

Endogenous Klebsiella pneumoniae endophthalmitis (EKPE) carries an extremely poor visual prognosis.
In patients admitted to general hospitals with K. pneumoniae liver abscess, a high index of suspicion of EKPE is recommended, and early referral to ophthalmology services advised.
Early surgical intervention in EKPE can salvage vision in this otherwise devastatingly blinding disease.

Figure

A, B: Intraoperative photographs of the posterior segment of the eye, showing retinal detachment with a subretinal abscess in the right eye (A) and a subretinal abscess in the left eye (B); the white arrows indicate the optic nerves. C: Computed tomography (CT) image of the orbits at presentation, showing left-sided proptosis with associated inflammation of the sclera (white arrow) and periorbital soft tissues. D: Abdominal CT scan, showing a 5.0 × 5.7 cm abscess (white arrow) in segments V/VIII of the liver. E, F: Slit lamp photos of the right (E) and left (F) eyes 13 days after initial presentation.

News briefs

The BMJ questions e-cigarettes endorsement

The BMJ has questioned the decision by Public Health England — (mission statement: “We protect and improve the nation’s health and wellbeing, and reduce health inequalities”) — to endorse the use of e-cigarettes as an aid to quitting smoking. In a report released at the end of August PHE concluded that e-cigs were “95% less harmful” than conventional cigarettes and described them as a potential “game changer” in tobacco control. In The BMJ Professor Martin McKee and Professor Simon Capewell said the available evidence, including a recent Cochrane review, did not show clearly that e-cigs were as effective as established quitting aids. “We might also expect that the prominently featured ‘95% less harmful’ figure was based on a detailed review of evidence, supplemented by modelling”, wrote McKee and Capewell. “In fact, it comes from a single [sponsored] meeting of 12 people.” The sponsors included a CEO with previous funding from British American Tobacco. One of the 12 was a chief scientific advisor with declared funding from an e-cigarette manufacturer, and Philip Morris International. “None of these links or limitations are discussed in the PHE report”, McKee and Capewell wrote.

Dramatic rise in antibiotic use globally

Nature reports that “antibiotic use is growing steadily worldwide, driven mainly by rising demand in low- and middle-income countries”, citing the latest report from the Center for Disease Dynamics, Economics and Policy. The organisation used a review of data from scientific literature, and national and regional surveillance systems to calculate and map the rate of antibiotic resistance for 12 types of bacteria in 39 countries, and trends in antibiotic use in 69 countries over the past 10 years or longer. “Global antibiotic consumption grew by 30% between 2000 and 2010. This growth is driven mostly by countries such as South Africa and India, where antibiotics are widely available over the counter and sanitation in some areas is poor.” The report also found that the use of antibiotics in livestock is growing worldwide, particularly in China, which used about 15 000 tonnes of antibiotics for this purpose in 2010, and is projected to double its consumption by 2030.

Child mortality under six million for first time

A new World Health Organization report says deaths among children aged 5 years and under worldwide have more than halved over the last 25 years, falling from 12.7 million a year in 1990 to 5.9 million in 2015. “While progress has been substantial, a 53% drop in child mortality is far short of the Millennium Development Goal, where countries agreed to reduce child mortality between 1990 and 2015 by two-thirds.” Around 16 000 children under 5 still die every day, most from diseases that are readily preventable or treatable, says the report. Around 50% of global deaths among the under 5s occur in sub-Saharan Africa, while 30% occur in southern Asia. Approximately 45% of deaths among the under 5s occur in the first 28 days of life. One million infants die on the day they are born, and nearly 2 million during the first week following birth. Leading causes of death in this group include complications during labour, premature birth, pneumonia, sepsis, diarrhea and malaria. Most of the remaining deaths among the under 5s are tied to undernutrition.

Static electricity next frontline in malaria control

Dutch researchers have come up with a way of improving the efficacy of mosquito nets using static electricity, according to a report in The Economist. With the WHO reporting a 60% drop in deaths caused by malaria since 2000, In2Care, a Dutch mosquito-control firm, is finding a way to deliver insecticides embedded in mosquito nets more effectively to the target insect. “Current mosquito nets are woven from fibres impregnated throughout with an insecticide”, The Economist reports. “This permits them to be washed and used for years without loss of potency. But it also means this potency is not as great as it could be, because the insecticide is released only slowly by the fibres. Using static electricity, by contrast, means all of the insecticide is held on the surface of a net’s fibres. Much larger doses can thus be transferred to an insect which blunders into the net. In addition, a wide range of insecticides — and even, possibly, the spores of a fungus harmless to people but lethal to mosquitoes — can be applied to the fibres.”

Government policies driving health divide

More than a fifth of patients in some areas have avoided seeing a doctor or filling a prescription even though they need care, with many saying they are put off by the cost.

Although a majority Australians report little difficulty in seeing their GP, the latest snapshot of patient experience from the National Health Performance Authority shows that in parts of rural New South Wales, Queensland, Western Australia and Tasmania, many people are avoiding or delaying treatment because of cost, running the risk of developing more serious and expensive-to-treat health problems.

Just as worrying, in some areas up to one in 10 say they cannot afford to fill their prescriptions, raising concerns around the management of serious chronic diseases such as diabetes and the treatment of infections.

The results underline the city-country divide in access to affordable care. While Australia-wide it was common for between 15 and 25 per cent of patients to complain of how long they have to wait to get an appointment with their GP, only around 2 to 4 per cent of those in major metropolitan areas said they could not afford to see their doctor, while in rural and regional Australia the rate was two to four times as high.

Chair of the AMA Council of General Practice Dr Brian Morton said strong competition between medical practices in urban areas drove high rates of bulk billing and helped contain patient out-of-pocket charges.

But the relative scarcity of doctors in country areas, and the need for adequate remuneration to recruit and retain them, encouraged lower rates of bulk billing and higher patient charges.

Dr Morton said this was not the fault of individual practitioners, and was instead the result of Federal Government policies including to screw down the value of Medicare rebates and hold back investment in training and support for rural GPs.

Dr Morton said of even greater concern when it came to preventive care was the relatively high instance of patients delaying or forgoing medicine because of expense.

He said patients, particularly those with a number of co-morbidities that had to be managed simultaneously, often faced a hefty monthly pharmacist bill.

For instance, he said, a patient with high blood pressure might be on three different medications which would cost more than $100 a month. If two or more people in a household have on-going courses of drugs, the costs can quickly mount up.

The consequences of foregoing treatment can be severe, Dr Morton said. Patients identified as at risk of heart disease who decide not to take prescribed statins can suffer a build-up of plaque in their blood vessels that can lead to blocked arteries, blood clots and other serious circulatory problems.

Protecting affordable access to care was at the centre of the AMA’s campaign late last year and early this year against the Abbott Government’s plans for a GP co-payment.

The AMA warned that charging a co-payment would deter many of the sickest and most vulnerable in the community from seeking care, creating the likelihood that their health would deteriorate and need more significant and expensive treatment later on.

And the latest official figures on national health spending suggest the pressure on patients to contribute to the cost of there is increasing.

The Australian Institute of Health and Welfare reported in September that the Commonwealth’s share of total health spending has plunged from almost 44 per cent to 41.2 per cent in just five years.

At the same time, individuals and families are shouldering more of the burden. In the past decade, the contribution of patients to the cost of health care has grown by an average of 6.2 per cent a year in real terms.

Adrian Rollins

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The updated Position Statement takes account of the most recent scientific evidence.

AMA President Professor Brian Owler said the AMA Position Statement focuses on the health impacts of climate change, and the need for Australia to plan for the major impacts, which includes reducing greenhouse gas emissions.

“It is the AMA’s view that climate change is a significant worldwide threat to human health that requires urgent action, and that human activity has contributed to climate change,” Professor Owler said.

“The evidence is clear – we cannot sit back and do nothing.

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