| OCR Text |
Show ORIGINAL CONTRIBUTION Optic Neuritis After Klebsiella Pneumonitis and Liver Abscess Hyeon-Seok Lee, MD, Kwang-Dong Choi, MD, Ji-Eun Lee, MD, and Hye-Kyung Park, MD Abstract: A 56-year-old woman developed a left optic neuropathy in the context of a Klebsiella pneumonitis that had also produced a liver abscess. Ophthalmic examination was normal apart from no light perception vision in the left eye and a left afferent pupil defect. Orbit and brain MRI revealed enhancement of the left optic nerve and several round enhancing areas in the gray-white junction of the frontal and temporal lobes consistent with micro-abscesses. Although the patient recovered systemi-cally with antiinfective and corticosteroid treatment, she retained no light perception vision in the left eye 4 months later. The association of Klebsiella pneumonitis and optic neuritis has not been described previously. We presume that the organisms spread hematogenously. (J Neuro-Ophthalmol 2009;29:134-135) Klebsiella pneumonitis can lead to endophthalmitis, especially in patients who also have pyogenic liver abscess or diabetes (1-4). We report a patient who developed optic neuritis without evidence of endophthal-mitis in the setting of Klebsiella pneumonitis, liver abscess, and cerebral microabscesses, a clinical circumstance not described previously. CASE REPORT A 56-year-old woman was admitted to the internal medicine service in our hospital with a 1-week history of fever, dyspnea, and cough followed by depressed menta-tion. Her previous medical history had been unremarkable. Departments of Neurology (H-SC, K-DC), Ophthalmology (J-EL), and Internal Medicine (H-KP), Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Busan, Korea. Address correspondence to Kwang-Dong Choi, MD, Department of Neurology, College of Medicine, Pusan National University 1-10 Ami-dong, Seo-gu, Busan, 602-739, Korea; E-mail: kdchoi@medimail. co.kr She had a body temperature of 38.5°C and a pulse rate of 90beats/min. The white blood cell count was 15,600 cells/mm3 with 90% neutrophils. The aspartate amino-transferase level was 175 IU/L, and the alanine amino-transferase level was 168 IU/L. Chest x-ray showed patches of infiltration in the right lower lung field. CT of the abdomen revealed signal abnormalities consistent with a pyogenic liver abscess (Fig. 1). Blood cultures docu-mented Klebsiella pneumoniae infection. After administration of intravenous ceftriaxone and moxifloxacin for 20 days, she became alert and reported poor vision in her left eye. Visual acuity was 20/20 in the right eye and no light perception in the left eye. Visual fields to finger confrontation were normal in the right eye. Pupils were equal in size in dim illumination, but there was a left afferent pupil defect. The range of extraocular movements was full, and there was no ptosis, exoph-thalmos, or conjunctival injection. There was no evidence of anterior or posterior chamber inflammation on portable slit-lamp examination. Findings on ophthalmoscopy were unremarkable. Postcontrast T1 MRI of the orbit and brain, per-formed 3 weeks after hospital admission, revealed FIG. 1. Axial CT of the abdomen performed at the time of hospital admission shows signal abnormalities consistent with pyogenic liver abscess (black arrow). 134 J Neuro-Ophthalmol, Vol. 29, No. 2, 2009 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Klebsiella Optic Neuritis J Neuro-Ophthalmol, Vol. 29, No. 2, 2009 FIG. 2. MRI performed 3 weeks after hospital admission. Postcontrast T1 axial (A) and coronal (B) MRI of the orbit shows enhancement of the orbital segment of the left optic nerve (white arrows). Postcontrast coronal MRI sections of the brain (C-D) show small round areas of enhancement at the cerebral gray-white junction consistent with microabscesses in the left frontal lobe (C, arrow) and temporal lobe (D, arrow). enhancement of the left optic nerve (Fig. 2A-B) and small round areas of enhancement in the left frontal and temporal lobes consistent with microabscesses (Fig. 2C-D). Lumbar puncture showed a normal opening pressure, cell count, protein level, and glucose level with a negative bacterial culture. Although the patient received 20 mg/day dexameth-asone intravenously followed by oral prednisolone, examination 4 months later showed no recovery of visual function. Ophthalmoscopy revealed left optic disc pallor. The patient recovered completely from all other aspects of her infection. DISCUSSION The most common ophthalmic complication of K. pneumoniae infection is endophthalmitis (1-4). Our patient did not have any apparent ophthalmic complications except unilateral optic neuritis. Paranasal sinuses and meningeal inflammation are potential routes of optic nerve infection in association with K. pneumoniae infection, but brain imaging in our patient did not show any abnormalities in the paranasal sinuses, and no meningeal inflammation was seen on the cerebrospinal fluid study (admittedly performed late in her clinical course). Considering the presence of microabscesses in the left frontal and temporal lobes and the pyogenic liver abscess, we presume that hematogenous spread is the likely underlying mechanism of optic neuritis in our patient. REFERENCES 1. Sng CC, Jap A, Chan YH, et al. Risk factors for endogenous Klebsiella endophthalmitis in patients with Klebsiella bacteremia: a case-control study. Br J Ophthalmol 2008;92:673-7. 2. Yang CS, Tsai HY, Sung CS, et al. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmol-ogy 2007;114:876-80. 3. Karama EM, Willermain F, Janssens X, et al. Endogenous endophthalmitis complicating Klebsiella pneumoniae liver abscess in Europe: case report. Int Ophthalmol 2008;28:111-3. 4. Seale M, Lee WK, Daffy J, et al. Fulminant endogenous Klebsiella pneumoniae endophthalmitis: imaging findings. Emerg Radiol 2007; 13:209-212. 135 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. |
