Endogenous endophthalmitis as a secondary bacterial infection following viral disruption of the blood-ocular barrier?Case report of 2 renal transplant patients

Background: Endogenous endophthalmitis is a rare but serious ocular infection. Seeding is usually haematogenous, and the visual prognosis is poor. We present 2 cases of bacterial endophthalmitis rapidly following viral retinitis in patients with a history of renal transplantation and no systemic symptoms of bacteraemia.

Case 1:

A 47 year old woman presented with features of bilateral panuveitis with retinitis, with no systemic symptoms.She had a history of renal transplantation. Escherichia coli had been isolated from multiple previous blood and urine cultures in the preceding months. A diagnosis of cytomegalovirus (CMV) retinitis was made on the basis of positive PCR from aqueous humour, and antiviral treatment commenced. Her left eye vision subsequently deteriorated. A repeat sample grew E. coli with a matching antibiogram to her previous isolates.

Case 2:

A 55 year old man presented with features of right-sided panuveitis and acute retinal necrosis, with no systemic symptoms. He had a history of renal transplantation. A diagnosis of varicella zoster virus (VZV) retinitis was made on the basis of positive PCR from the aqueous humour, and antiviral treatment commenced. His symptoms deteriorated, and Streptococcus pneumoniae was isolated by culture from a repeat sample. Imaging of the sinuses revealed inflammatory changes.

Conclusions:

We hypothesise that endophthalmitis in these two immunocompromised patients may have been opportunistically enabled by disruption of the blood-ocular barrier by the preceding viral infection, allowing a transient bacteraemia to seed. Whether there may be any role for prophylactic antibiotics in this context would benefit from further study.