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Taiwan Journal of Ophthalmology 3 (2013) 45e48
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Case report
Endogenous Serratia marcescens endophthalmitis associated with Port-a-Cath in
an oncology patient: A case report and review of the literature
Yi-Chieh Poon, Hsi-Kung Kuo*
Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 3 February 2012
Received in revised form
27 June 2012
Accepted 9 July 2012
Available online 20 August 2012
A 47-year-old woman with gum cancer was diagnosed with acute endogenous endophthalmitis. Serratia
marcescens was cultured from the vitreous and blood samples. A venous access port for chemotherapy
was the only identifiable source of infection. After receiving systemic antibiotics therapy, the patient
recovered from the bacteremia but lost her vision as a result of Serratia endophthalmitis.
Copyright Ó 2012, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights
reserved.
Keywords:
endogenous endophthalmitis
Port-a-Cath
Serratia marcescens
1. Introduction
Endogenous bacterial endophthalmitis is a serious and rare
complication of bacteremia that occurs with an incidence rate of
0.2%.1 It develops when pathogens reach the eye via the bloodstream, and cross the blood-ocular barrier to cause intraocular
infection. Risk factors for developing endogenous bacterial
endophthalmitis include diabetes mellitus, malignancy, intravenous drug use, and immunodeficient state. Common causative
bacteria differ according to geographic regions. In the non-East
Asian countries, the most common pathogen is Gram-positive
bacteria, such as Staphylococcus aureus and the Streptococcus
species; while in the East Asian countries, Klebsiella pneumoniae,
a Gram-negative bacteria is most common.2 In this case report, we
will present a case of endogenous bacterial endophthalmitis caused
by an unusual intraocular pathogen.
2. Case report
A 47-year-old woman presented to our emergency department
with acute onset of right eye pain, blurred vision, and tearing for 1
day. She had just been discharged from our hospital after receiving
chemotherapy, 1 week prior to her return to the emergency
* Corresponding author. Department of Ophthalmology, Kaohsiung Chang Gung
Memorial Hospital, Number 123, Ta-Pei Road, Niao-Sung District, Kaohsiung City
833, Taiwan.
E-mail address: [email protected] (H.-K. Kuo).
department due to eye pain. The patient had a low-grade fever but
no other systemic discomforts. The patient’s medical history was
significant for having type 2 diabetes mellitus for more than 10
years, and gum cancer which was diagnosed 2 years earlier. The
patient had been receiving concurrent chemoradiotherapy for gum
cancer ever since its diagnosis. Chemotherapy was administrated
through an implantable venous access device (Port-a-Cath) that
was implanted subcutaneously below her left clavicle (Fig. 1).
Upon examination at the emergency department, the patient
was only able to see hand motion at 30 cm away, and had an
intraocular pressure (IOP) of 27 mmHg in her right eye. Slit-lamp
examination showed that the cornea was edematous and was
coated on the endothelial side with keratic precipitates, and that
there were hypopyon and dense fibrinous exudates in the anterior
chamber of the eye. Examination of the fundus was obscured by the
intense inflammatory reaction in the anterior chamber and the
vitreous cavity. B-scan ultrasonography of the right eye revealed
dense and heterogenous opacities in the vitreous cavity (Fig. 2).
Orbital computed tomography image showed prominent periocular
fat stranding and diffuse scleral thickening (Fig. 3). The diagnosis of
endogenous endophthalmitis was made based on the above findings, and the patient was given a combination of vancomycin,
amikacin, and dexamethasone injected intravitreally into the eye.
Vitreous sample obtained on that day yielded the growth of Serratia
marcescens, while the blood samples drawn from the peripheral
blood were negative for bacterial growth.
The patient was promptly admitted into the hospital for intravenous antibiotic therapy, given through a peripheral venous
2211-5056/$ e see front matter Copyright Ó 2012, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.tjo.2012.07.002
46
Y.-C. Poon, H.-K. Kuo / Taiwan Journal of Ophthalmology 3 (2013) 45e48
Fig. 3. Computed tomography of the orbit showed extensive periocular fat stranding
and diffuse scleral thickening in the right eye.
Fig. 1. Chest X-ray revealed that the patient had an implanted Port-a-Cath.
catheter. A broad-spectrum antibiotic, cefepime, was initially used,
but was later switched to ceftriaxone according to drug sensitivity
results from the bacterial cultures. Ultrasonography of the liver,
cardioechography, urinalysis, and chest X-ray for infection survey
were performed, but all yielded negative results.
During hospitalization, the patient’s ocular inflammation signs
remained stationary, but she continued to have low-grade fever of
37.7e37.9 C. Then, during the third week of hospitalization, the
patient suddenly had a high fever of 39 C that was accompanied by
chills and local tenderness near the site of the implanted Port-aCath. Coincidentally, on the same day, the patient had just
switched from the use of a peripheral venous catheter line to the
use of the Port-a-Cath for the administration of antibiotic therapy.
Because of high fever, blood cultures were obtained, and both
samples from the Port-a-Cath and the peripheral catheter yielded
Fig. 2. B-scan showed that there were dense vitreous opacities.
S. marcescens. Despite the high suspicion for Port-a-Cath-related
infection, the patient needed this venous access port for chemotherapy, thus the decision was made not to remove it for tip culture.
Systemic antibiotic was switched to ceftazidime because of
persistent Serratia bacteremia and that this was a catheter-related
bloodstream infection.
The patient received a total of 6 weeks of systemic antibiotic
therapy, and was discharged from the hospital after subsequent
blood cultures no longer yielded bacterial growth. Despite the
improvements in her systemic conditions and ocular inflammation,
the patient’s right eye vision eventually progressed to no light
perception, and phthisis bulbi developed.
3. Discussion
S. marcescens, an aerobic, Gram-negative bacilli, has become an
increasingly common cause of hospital-acquired infections
worldwide.3e5 It can cause a variety of diseases, including respiratory tract infections, urinary tract infections, bacteremia, wound
infections, keratoconjunctivitis, and meningitis.6 Outbreaks of
S. marcescens bacteremia in the nosocomial setting has been associated with high mortality rates of 25.4e32%,4,5 and have been
linked to contaminated prefilled syringes and drug vials,7,8 multiple
dose usage for single-use drug vials,9 and inappropriate aseptic
techniques of the healthcare personnels.10
Endogenous endophthalmitis caused by S. marcescens is rare.
Based on our literature search, fewer than 10 well-documented
cases (not including cases written in languages other than in
English) have been reported to date (Table 1).6,11e19 Endogenous
Serratia endophthalmitis has been associated with intravenous
drug therapy, general surgery, and the use of indwelling catheters.6
Additional risk factors include diabetes mellitus, malignancy, and
immunocompromised state.
S. marcescens can be highly destructive to the eye, owing to its
ability to secrete proteases that cause the loss of proteoglycan
ground substances which then lead to the dispersal of collagen
fibrils, liquefactive necrosis, and subsequently, ocular perforation.6
Endogenous Serratia endophthalmitis often leads to very poor
visual outcomes. In their review, Equi and Green6 found that nearly
Y.-C. Poon, H.-K. Kuo / Taiwan Journal of Ophthalmology 3 (2013) 45e48
47
Table 1
Clinical characteristics of S. marcescens endogenous endophthalmitis in our case and previous reports.
Author (reference)
Age, y
Sex
Comorbidity or risk factors
Source of positive
bacterial isolates
Intravitreal
antibiotics
Systemic antibiotics
Final outcome
Gammon et al.11
60
Female
Aqueous, urine
None
Gentamicin/amikin
Death
Radda12
59
Male
Vitreous
None
Amoxicillin/carbenicillin
and gentamicin/ticarcillin/
cefotaxime
Evisceration
de Courten et al.13
10 days
male
Craniotomy for intercavernous
aneurysm, indwelling
urinary catheter
Chronic lymphatic leukemia,
diabetes mellitus, transurethral
electroresection of prostate for
prostate adenoma, hemodialysis,
Colostomy for unperforated anus
Vitreous, blood
None
Enucleation
Alverez et al14
32
male
HIV infection, intravenous
drug user
Vitreous
Tobramycin,
vancomycin
Al Hazzaa et al.15
3 days
Umbilical artery catheter
Blood, catheter
tip, aqueous
Renal abscess
pus culture
Vitreous, aqueous
humor, blood culture
Vitreous, blood,
catheter tip
Gentamicin,
cefazolin
Vancomycin,
amikin
Ceftazidime,
vancomycin
Vancomycin,
gentamicin
Ceflatonin and ampicillin/
ampicillin and amikin
Ceftazidime, amikin, and
vancomycin/ceftriaxone
and amikin
Gentamicin
Cefazolin/pefloxacin/
ceftizoxime
Piperacillin, vancomycin,
and gentamicin/cefotaxime
Vancomycin and
gentamicin/aztreonam
No light
perception
Enucleation
Blood, sputum,
Ceftazidime,
vancomycin
None
Amikin,
vancomycin
Cefuroxime and gentamicin
Death
Amikin/ciprofloxacin
Cefepime/ceftriaxone/
ceftazidime
Enucleation
Phthisis bulbi
Lin et al.
68
Not
specified
Female
Marinella et al.17
48
Male
Equi et al.6
54
Female
Williams et al.18
56
Female
Latorre19
Our case
20 days
47
Female
Female
16
Diabetes mellitus, renal abscess
Diabetes mellitus, hemodialysis,
temporary central venous catheter
Diabetes mellitus, hemodialysis,
hypertension, temporary
central venous catheter
Bowel resection for Crohn’s
disease, pneumonia
Umbilical artery and vein catheters
Diabetes mellitus, gum cancer
with port-a-cath
all of the previously reported cases of endogenous Serratia
endophthalmitis resulted in worse than no light perception,
including death, evisceration, and phthisis bulbi.
Because of this organism’s ability to produce pigment, pigmented hypopyon, such as pink15 or dark6 hypopyon can sometimes also be observed in case of endogenous endophthalmitis.
However, even though this is a distinctive feature of Serratia
infection, it cannot be relied upon for diagnosis or identification of
the organism, because only a minority of S. marcescens strains
elaborates pigment.6 In our patient, no particular discoloration or
pigmentation of hypopyon upon presentation was noted.
Management of this organism can be difficult because it is
typically a multi-drug resistant organism. A 10-year retrospective
study4 at a tertiary-care hospital showed that the resistance rate to
third-generation cephalosporin was about 46%, extended-spectrum
penicillin was 57%, and ciprofloxacin was 32%.
Bacteria can be introduced into the blood resulting in bacteremia through various portals of entry, and may cause endogenous
endophthalmitis when the bacteria are inoculated in the eye via
hematogenous spread. Our patient had no history of penetrating
injury or surgery to the eye, which suggests that her endophthalmitis was endogenous, and that the bacteria came from the
bloodstream. Even though S. marcescens was cultured from our
patient’s vitreous initially, her first set of blood culture, which was
obtained from the peripheral vein instead of from her Port-a-Cath,
had no bacterial growth. In a review comparing blood cultures
obtained from intravascular catheters and peripheral vein, Falagas
et al.20 showed that the blood drawn from peripheral vein had
a higher false negative rate, and could result in undertreatment of
true bacteremia. Furthermore, we speculate that based her initial
subclinical systemic presentation, the bacterial load in her blood
could have been relatively low, which may have resulted in a falsely
negative bacterial yield. As a survey for infection source revealed no
apparent source of infection other than her catheter, and also
because subsequent blood culture obtained from the Port-a-Cath
grew the same bacteria as the vitreous, makes the Port-a-Cath
the mostly likely portal of entry for the bacteria. In addition to
Blood
Vitreous, blood
Phthisis bulbi
Phthisis bulbi
Enucleation
having an intravascular device, she also had type 2 diabetes mellitus and gum cancer, which together made her vulnerable to
developing endogenous endophthalmitis.
The Port-a-Cath is an implantable venous access device that is
composed of a catheter that connects a portal to the large vein. It is
commonly used for receiving chemotherapy or parenteral nutrition
in cancer patients, but is also the leading cause of health-care related
bloodstream infections21 in this group of patients. The definitive
diagnosis of catheter-related blood stream infections is typically
made by the removal of the catheter and obtaining a catheter tip
culture. However, catheters cannot always be removed easily, especially when the catheters are long-term catheters, need to be surgically removed, or when insertion of a new catheter is difficult. The
Port-a-Cath of our patient was not removed because she depended
on it for chemotherapy, and because the patient was physically weak
and could not withstand another surgical procedure.
In a recently updated guideline by the Infectious Diseases
Society of America22 in 2009, two methods for definitive diagnosis
of catheter-related bloodstream infection (CRBSI) without the
removal of catheters were also listed, which are the quantitative
blood culture method and the differential time to positivity
method. Two blood samples need to be obtained, one drawn from
the catheter, and the other from the peripheral vein. For the
quantitative blood culture method, a definitive diagnosis of CRBSI is
made when the colony count of microbes grown from the blood
obtained from the catheter is threefold greater than the colony
count of the blood obtained from a peripheral vein. For the differential time to positivity method for diagnosing CRBSI, growth of
microbes from the blood drawn from a catheter occurs >2 hours
before microbial growth is detected in a blood sample obtained
from a peripheral vein. The above catheter-sparing methods are
high in sensitivity and specificity (sensitivity 93% and 89e90%,
respectively; specificity 97e100% and 72e87%, respectively),21
and facilitate accurate diagnosis of CRBSI without the removal of
catheters. The differential time to positivity method is a simple
technique and can be done in most laboratories; however, the
routine recording of time to positivity for microbial growth was not
48
Y.-C. Poon, H.-K. Kuo / Taiwan Journal of Ophthalmology 3 (2013) 45e48
implemented in our microbiology lab until recently. Therefore, this
piece of information was not available to us, and a definite diagnosis of Port-a-Cath infection could not be made in our case.
Nevertheless, a high degree of suspicion remains for the Port-aCath as the source of infection, as no other apparent source or
portal of entry for infection could be found in our patient.
In the case of our patient, it is possible that the bacteria had
already been colonized within the port, and may have been washed
into the bloodstream with each use of the Port-a-Cath, which
consequently resulted in the infection of the eye and the bloodstream. Therefore, it is important to recognize Port-a-Cath as
a potential portal of entry for bacteria in cancer patients who
present with endogenous endophthalmitis, particularly when no
other infection source could be identified.
In conclusion, because endogenous endophthalmitis is a severe
complication of bloodstream infection with devastating consequences, a detailed evaluation, including physical examination and
recording of medical history is essential, so that any indwelling
catheters or intravascular devices, particularly the Port-a-Cath in
cancer patients are not missed. Furthermore, when unusual pathogens are encountered in cancer patients with endogenous
endophthalmitis, catheter- related infections should be ruled out
because intravascular devices may allow unusual and aggressive
pathogens to gain access to the eye via the bloodstream.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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