Author Affiliations: Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida.
Salmonella is a rare cause of endogenous endophthalmitis.1- 4 We describe a healthy child who developed severe endogenous Salmonella endophthalmitis after an episode of self-resolved gastroenteritis. In a literature search, no other cases are described with this clinical history in an immunocompetent patient.
A 12-year-old boy with unremarkable medical, ocular, and family history had sudden-onset, rapidly progressive vision loss in the left eye for 2 days. His initial visual acuity was light perception and he had mild pain. The right eye was normal. Ten days prior to his initial visit, he reported a 4-day history of fever reaching a temperature of 38.9°C and a diarrheal illness that was treated at home with oral fluids and not medically evaluated. A history of consuming possibly undercooked chicken wings was elicited. At the initial visit, his vital signs were stable and the diarrhea had resolved.
Intravitreous tap and injection of vancomycin hydrochloride, 1 mg, ceftazidime, 2.25 mg, and dexamethasone sodium phosphate, 0.4 mg, was performed on the day of the initial visit, and broad-spectrum treatment with intravenous vancomycin and ceftazidime was started (Figure, A). Within 12 hours, the vitreous culture was positive for Salmonella serotype B sensitive to fluoroquinolones, aminoglycosides, cephalosporins, trimethoprim sulfate, ampicillin, and meropenem. Because visual acuity remained at light perception and the clinical signs were not improving, pars plana vitrectomy and lensectomy were performed on the second posttreatment day. Intraoperatively, multiple peripheral retinal tears and sclerotic retinal vessels were noted. Two additional intravitreous injections of amikacin sulfate and ceftazidime were administered during follow-up. The extensive systemic workup ruled out an immunocompromised state. Blood culture results were negative. Stool culture was positive for Salmonella serotype B. Echocardiography, abdominal ultrasonography, chest radiography, computed tomography of the brain, computed tomography of the abdomen and pelvis, and an upper gastrointestinal tract series with a small-bowel series failed to identify any additional foci of infection. The patient received intravenous meropenem for 6 weeks. At the 4-month follow-up, visual acuity was no light perception and ocular hypotony was observed (Figure, B).
Figure. Slitlamp photographs of the left eye. A, On the first postoperative day, the eye was inflamed with hypopyon and fibrin in the anterior chamber and the visual acuity was light perception. B, At the 4-month follow-up, a clear cornea and ocular hypotony were observed and the visual acuity was no light perception.
Salmonella gastroenteritis is relatively common, affecting an estimated 1 to 4 million people per year in the United States alone.5 The global impact of nontyphoidal Salmonella is high, with an estimated 93.8 million illnesses and 155 000 deaths each year. The incidence is highest in Southeast Asia, East Asia, and Central Europe.6 There are more than 2300 Salmonella serotypes. The most frequent group B serotypes include Typhimurium and Heidelberg. Usually self-limiting symptoms include moderate fever, nausea, vomiting, diarrhea, and variable abdominal pain. Immunosuppression, extremes of age, decreased gastric acidity, and altered intestinal function predispose to more severe gastroenteritis. Other than with severely ill or immunocompromised patients, fluid and electrolyte replacement is the mainstay of therapy. The pathogenicity of Salmonella is multifactorial and attributed in part to production of cholera toxin–like and Escherichia coli heat-labile enterotoxin–like toxins. Transient bacteremia occurs in an estimated 1% to 4% of patients and may result in metastatic seeding in predisposed patients: cardiac seeding with cardiac structural abnormalities, intravascular seeding with atherosclerotic disease, bone and joint seeding with prostheses, and central nervous system seeding in neonates.5
Pediatric bacterial endogenous endophthalmitis is rare (0.1%-4% of all endogenous bacterial endophthalmitis, which in turn accounts for 2%-8% of all reported endophthalmitis cases).7 Common sources include wound infection, meningitis, endocarditis, urinary tract infection and indwelling intravenous catheters, and hemodialysis fistulas. Pediatric endogenous endophthalmitis often is not suspected and is misdiagnosed.7
Endogenous Salmonella endophthalmitis is a rare condition, with only 11 cases reported in the English literature (Table).1- 4 The visual prognosis is usually poor, with reported outcomes being visual acuity of no light perception and involved eyes often requiring enucleation.
Correspondence: Dr Rachitskaya, Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17th St, Miami, FL 33136 (firstname.lastname@example.org).
Financial Disclosure: None reported.
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