ID conference นพ. ก าพล ส วรรณพ มลก ล แพทย ประจ าบ านต อยอดหน วยโรคต ดเช อ

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Chester Baldwin
5 years ago
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1 ID conference นพ. ก าพล ส วรรณพ มลก ล แพทย ประจ าบ านต อยอดหน วยโรคต ดเช อ

2 Present illness ผ ป วยชายไทยค อาย 66 ป CC: ตาโปนมากข นมา 2 ว นก อนมา รพ. PI: 12 days PTA ม ไข หนาวส น ปวดเม อยกล ามเน อ ไม ม อาการอ นๆ ไปรพ.ได ยาแก อ กเสบก น อาการย งไม ด ข น 10 days PTA ผ ป วยไปพบแพทย อ กคร ง แพทย ตรวจเล อดและ บอกว าไม ม ความผ ดปกต มากน ก ให กล บไปด อาการท บ านได

3 PI: 8 days PTA ผ ป วยย งม ไข อย หล งจากไปพบแพทย ตามน ด เพ อตรวจเล อดซ า แพทย บอกว าสงส ยไข เล อดออก จ งให ผ ป วยนอนพ กร กษาต วใน รพ. 7 days PTA เร มร ส กว าตาขวาม ว ตาแดงข นแต ไม เจ บปวด อะไร ไม ม เห นภาพซ อน กลอกตาได ปกต จ กษ แพทย จ งว น จฉ ยว าเป น bacterial conjunctivitis และ ได ร บยาแก อ กเสบมาหยอดตา

4 PI ; 5 days PTA ปวดศ รษะต อๆบร เวณหน าผาก ร าวไปกระบอก ตาข างขวา ไอหร อจามไม ได ท าให ปวดมากข น บ ตรชายส งเกตว าตาสองข างของผ ป วยโปนและแดงมาก ข นกว าเด ม ไปพบแพทย อ กคร งได เปล ยนการว น จฉ ย เป น Endophthalmitis และเร มให ยาปฏ ช วนะทางหลอด เล อดด า จ งส งต วมาร กษาต อท รพ.จ ฬาฯ

5 Past History - เป นโรคความด นโลห ตส ง on HCTZ(50) ½*1 - ส บบ หร 30-pack-year - ไม ด มเหล า - ไม เคยแพ ยา

6 Physical examination A Thai male, looked acutely ill Vital sign : BT= 38 c, BP= 140/90 mmhg RR=20/min, HR=100/min HEENT: not pale, no Jaudice : marked injected conjunctiva both eyes. : Proptosis and chemosis of both eyes, Rt>Lt : normal ear drum, nasal mucosa : not injected pharynx

10 Physical examination Heart : normal heart sound, no murmur, regular Lung : no tachypnea : normal breathsound : no adventitious sound

11 Physical examination Abdomen : normal bowel sound : soft, not tender Extremities: no edema : no hepatosplenomegaly

12 Neurological examination Rt Lt : Pupil 2 mm NRTL RTL : EOM limited all direction full : VA LP 20/70 : Corneal reflex +ve +ve

13 Neurological examination : Motor : grade V all : sensory : intact : clonus : negative : BSS : plantar flexor response both feet

14 27/6/50 Day1 OPD Eye Rt Lt VA light projection 20/70 General worsening of proptosis EOM limited all full

15 OPD Eye Rt Lt : Conjunctiva chemosis chemosis nasal side : Cornea stromal edema 2+ clear : A/C cell

16 Ophthalmic Ultrasound Rteye thickness : Dense vitreous opacity : Retinal detachment : dense subretinal opacity, increased RC Lt eye : Moderate vitreous opacity confined to posterior pole : no retinal detachment. Slightly increased RC thickness

17 Problem list 1.Subacute fever and endophthalmitis of both eyes

18 Lab CBC Hct=31.2 BUN/Cr -16/0.8 -WBC=22,960 N=89%, L=8% -Platelet=133,000 FBS - 98 mg%

19 Lab LFT : TB/DB =2.51/1.28 :AST/ALT=80/96 :ALP=506 TP/Albumin : 5.2/2.4 PT/INR : 13.2/1.1 PTT : 28.8

Surgery Surgery CeftriaxoneD1 CT brain Ciprofloxacin D1

20 Surgery Vitreous G/S,AFB,KOH Vitreous C/S aerobe, anarobe,tb,fungus H/C*II Surgery Sputum G/S,AFB,C/S Surgery Surgery CeftriaxoneD1 CT brain Ciprofloxacin D1 Fortum D1 Vancomycin D1 USG Ciprofloxacin D6 Fortum D6 Vancomycin D6

21 Surgery Vitreous G/S Vitreous C/S CeftriaxoneD3 CeftriaxoneD9

26 CT brain with contrast 27/6/50 (Day1) : normal brain parenchyma : Enhanced hyperdense lesion with air bubble at Rt lacrimal gland with extension to preseptal area of Rt globe.enlarged Rt optic nerve : Normal paranasal sinus and mastoid air cell

27 DDX Endogenous : Bacterial eg. Staphylococcus aureus, streptocooci, gram negative bacilli : Fungal eg. Candida, Aspergillus, Fusarium Exogenous

28 28/6/50 (Day 2) Surgery : PPV with vancomycin and fortum injection to Lt eye. : vitreous tapping with vancomycin and fortum injection to Rt eye.

29 28/6/50 (Day 2) : Rt eye : Vitreous Gram stain : gram ve rod : Vitreous AFB, KOH : Negative

30 28/6/50 (Day 2) : Lt eye : Vitreous Gram stain : Negative : Vitreous AFB, KOH : Negative : Vitreous C/S : No Growth : Vitreous C/S for anarobe : No Growth : Vitreous C/S for TB, Fungus : pending

31 28/6/50 (Day 2) PM Hypoxemia, Tachypnea (RR=24/min) ABG: ph = 7.49 PaO2 = 51 PCO2= 31.1 HCO3= 23.6 O2sat = 89%

32 24/6/50

33 27/6/50

34 28/6/50 (Day 2) CXR : Reticulonodular RUL Sputum Gram stain : no organism Sputum Culture : NG Sputum AFB : no organism Rx : O2 canula 3 LPM = 95-96% : continue ATB

35 28/6/50(Day2) Vitreous C/S : Klebsiella pneumoniae : Vitreous C/S for anarobe : NG : Vitreous C/S for TB, Fungus : pending : Hemoculture fore aerobe and anaerobe : NG

36 29/6/50 (Day 3) UltraSonoGraphy : A 3.8x2.4 cm. round welldefined anechoic lesion and a few small calcification locating just anterior to gallbladder, complicated liver cyst is probable. However, primary cystic tumor cannot be totally excluded. Please follow.

37 30/6/50 (Day4) Surgery : PPV with vancomycin and fortum injection to Lt eye. : vitreous tapping and vancomycin and fortum injection to Rt eye.

38 30/6/50 (Day4) : Rt eye : Vitreous Gram stain : gram ve rod : Vitreous AFB, KOH : Negative : Vitreous C/S : Klebsiella pneumoniae, ESBL (extended spectrum beta-lactamase) negative : Vitreous C/S for anarobe : NG

39 30/6/50 (Day4) : Lt eye : Vitreous Gram stain : Negative : Vitreous AFB, KOH : Negative : Vitreous C/S : Negative : Vitreous C/S for anarobe : NG

40 2/7/50(Day7) Rt eye Vitreous G/S-gram negative rod Vitreous C/S-Klebsiella pneumoniae Vitreous C/S anaerobe - NG

41 2/7/50(Day7) Lt eye Vitreous G/S Negative Vitreous C/S - NG Vitreous C/S anaerobe - NG

42 2/7/50 (Day6) Sputum G/S : gram negative rod, gram positive cocci Sputum AFB : negative

43 Ophthalmic ultrasound (2/7/50) Rt eye : most likely pandophthalmitis Lt eye : mass at nasal side, with subvitreal hemorrhage, most likely subretinal abscess

44 3/7/50(Day7) Lt eye Vitreous G/S Negative Vitreous C/S - NG Vitreous C/S anaerobe - NG

45 6/7/50(Day10) Surgery : Rt eye excenteration Operative finding : injected at sclera, cornea, yellow pus discharge from orbit injection PPV and Intravitreal fortum Lt eye

46 6/7/50(Day10) Vitreous Gram stain Rt eye : Negative Lt eye : Negative Vitreous culture for aerobe Rt+Lt eye :NG Vitreous culture for anaerobe Rt eye :NG

47 LFT 27/6/50 29/6/50 4/7/50 TB DB AST ALT ALP

48 Ophthalmitis Definition 1. Endopthalmitis 2. Pandophthalmitis : endophthamitis + orbital cellulitis ( marked edema and erythema of the eyelids, proptosis and limitation of extraocular movements)

49 Anatomy The eye is divided into 2 parts 1. anterior segment aqueous humor, produced and resorbed 2. Posterior segment vitreous body, never regenerated

50 pathogenesis Exogenous organism from external source. - confined to the eye - rarely any systemic symptom Endogenous - organism from hematogenous. - Prominent symptoms of underlying systemic infection

51 Endophthalmitis Categories 1. Acute postcataract coagulase -ve staphylococci 2. Bleb-related Viridans streptococci, Streptococcus pneumoniae, Haemophilus influenza 3. Posttraumatic Bacillus cereus

52 Endophthalmitis Categories 4. Endogenous Staphylococcus aureus, streptocooci, gram negative bacilli 5. Chronic pseudophakic Propionibacterium acnes 6. Fungal Candida, Aspergillus, Fusarium

53 Acute postcataract endophthalmitis Most common type With in 1 week of surgery Eye pain(74%), redness(82%) and decreased vision(94%) Rapidly developed within 24 hrs Signs of systemic illness are absent Eye injected and hypopyon

54 Acute postcataract endophthalmitis 70% coagulase-negative staphylococci are major pathogens 10% Staphylococcus aureus 9% Streptococci spp.

55 Bleb-related Endophthalmitis Filtering bleb control glaucoma, refractory to medical management Occur abruptly, months to years after bleb surgery S. pneumoniae and viridans streptococci 50% Haemophilus influenza, Morexella catarrhalis

56 Filtering bleb

57 Posttraumatic endophthamitis Most likely lacerating injury, retained intraocular foreign bodies Bacillus cereus is major cause fulminant endophthalmitis Other cause eg. coagulase-negative staphyloocci, streptococci, gram-negative bacilli

58 Endogenous bacterial endophthalmitis Bacteremia, significant focus eg. Endocarditis, intraabdominal abcess. Other source eg. Hepatic abscess, urinary tract infection, meningitis and infected indwelling catheter.

59 Endogenous bacterial endophthalmitis Considered in patient who presents with acute vitritis and hypopyon Patient with endocarditis monitored for new visual complaint

60 Chronic Pseudophakic Endophthalmitis Indolent infection Almost always due to Propionibacterium acnes After cataract surgery with artificial intraocular lens

61 Fungal endophthamitis Major cause : Candida, mold Candida endophthalmitis should be distinguished from Candida chorioretintis(clear vitreous) Untreated Candida chorioretintis progress to endophthalmitis Usually presumptive, clinical setting of documented candidemia

62 Fungal endophthamitis Usually exogenous source eg. Eye surgery, penetrating trauma Aspergillus is the most common organism Mostly develop after surgery, usually presents as subacute, 2-6 wks post operatively

63 Diagnosis Afebrile and no signs of systemic infection except endogenous endophthalmitis and pandophthamitis B-scan : ultrasound of the globe of the eyes. Vitreous gram stain, culture Vitreous washing more likely to yield positive culture

64 Treatment Acute bacterial endophthamitis - medical emergency treatment 1. intravitreal antibiotic Vancomycin + Ceftazidime/Amikacin - Ceftazidime is preferred

65 Treatment 2. Vitrectomy : rapid worsening of vision and marked intraocular inflammation : posttraumatic, bleb-related, endogenous endophthalmitis 3. Intravenous Antibiotic : Vancomycin plus ceftazidime

66 Classification of Endophthalmitis Am Fam Physician 1999;60:510-4

67 Infective agents that commonly cause endophthalmitis I. Bacteria A. Gram-positive cocci 1. Staphylococcus a. S. aureus b. viridans group B. Gram-positive bacilli 1. Bacillus a. B. cereus b. B. subtilis 2. Corynebacterium 3. Propionibacterium acnes C. Gram-negative cocci 1. Neisseria 2. Moraxella D. Gram-negative bacilli 1. Acinetobacter 2. Haemophilus influenzae 3. Pseudomonas 4. Enterobacteriaceae a. E. coli b. Klebsiella c. Proteus Stephan J.Ryan Retina th edition

68 Infective agents that commonly cause endothalmitis II. Higher bacteria A. Nocardia spp. B. Actinemyces C. Mycobacterium III. Fungi A. Candida B. Aspergillus C. Histoplasma capsulatum D. Blastomyces dermatitidis IV. Helminths A. Onchocerca volvulus B. Taenia solium C. Toxocara canis V. Protozoa A. Toxoplasma gondi VI. Ectoparasites A. Maggots (myiasis) Stephan J.Ryan Retina th edition

69 Microbiology of Causative Organisms in Bacterial Endogenous Endophthalmitis Cases Published in the Literature from 1986 to 1998 by Geographic Origin of Cases Systematic reviews of 87 references, 255 eyes with endogenous endophthalmitis Ophthalmology 2000;107:

70 Sources of Infection Wong Greenwald Patients(%) Hepatobiliary/liver abscess 64(31) Urinary tract 22(11) 10(14) Skin/joints 16(8) 6(8) Endocarditis 15(7) 10(14) Respiratory tract 14(7) 4(6) Meningitis 14(7) 19(26) Cathether related 7(3) Peritonitis 7(3) 8(11) Unknown 47(23) 19(26) Ophthalmology 2000;107:

Predisposing medical conditions include uncontrolled diabetes, cardiac disorders, and gastrointestinal and malignant disease The most frequent underlying

71 Predisposing medical conditions include uncontrolled diabetes, cardiac disorders, and gastrointestinal and malignant disease The most frequent underlying problems are endocarditis gastrointestinal tract infection, and pneumonia Hypopyon in a patient with metastatic bacterial (Staphylococcus aureus) endophthalmitis.

72 BACTERIAL ENDOPHTHALMITIS Endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent into the posterior segment of the eye Infectious agents generally gain access to the posterior segment of the eye following one of three routes: (i) as a consequence of intraocular surgery (postoperative) : post cataract surgery (coagulase-negative staphylococci (70%)) (ii) following a penetrating injury of the globe (posttraumatic) : 1.) Staphylococci 2.) Bacillus cerus (iii) from hematogenous spread of bacteria to the eye from a distant anatomical site (endogenous) : relative rare, accounting for only 2 to 8% of all endophthalmitis CLIN. MICROBIOL. REV. 2002;15(1):

73 Endogenous Endophthalmitis Populations at greatest risk include immunocompromised patients or those on immunosuppressive therapy, patients with prolonged indwelling devices, and intravenous drug abusers Common causes of endogenous bacterial endophthalmitis include S. aureus, B. cereus, and gram-negative organisms, including Escherichia coli, Neisseria meningitidis, and Klebsiella spp. Bacillus spp. are a primary bacterial cause of endogenous endophthalmitis in intravenous drug abusers Candida albicans is the most common etiological agent of endogenous fungal endophthalmitis CLIN. MICROBIOL. REV. 2002;15(1):

74 Rapid nature of B. cereus endophthalmitis At 6 h postinfection, little inflammation is observed on gross histological examination. By 9 h postinfection, extensive inflammation is seen in the posterior and anterior segment. Corneal and conjunctival edema and dissolution of retinal layers are apparent. By 12 h, the posterior an anterior segments are engorged with inflammatory cells and fibrin, and the architecture of the globe has begun to degrade CLIN. MICROBIOL. REV. 2002;15(1):

75 Choice of Antimicrobial Agent The recommended management of bacterial endophthalmitis includes direct injection of antibiotics into the vitreous Systemic antibiotics have also been used concurrently for bacterial endophthalmitis although some potentially effective antibiotics (vancomycin and aminoglycosides) do not penetrate readily into the vitreous, due in part, to the protective effect of the blood-ocular fluid barrier. New data suggest that fluoroquinolones penetrate into the inflamed and non-inflamed vitreous better than other classes of antibiotics CLIN. MICROBIOL. REV. 2002;15(1):

76 Choice of Antimicrobial Agent Many clinicians recommended combination with intravitreal antibiotics in management of some severe endophthalmitis cases The three most commonly utilized antibiotics for intravitreal administration include 1.0 mg of vancomycin, 0.4 mg of amikacin (retinal microvasculitis) and 2.2 mg of ceftazidime Fluoroquinolones are not widely used for direct intraocular administration, due in part to concerns regarding possible toxicity CLIN. MICROBIOL. REV. 2002;15(1):

77 Vitrectomy Although intravitreal antibiotic therapy can provide effective bacterial killing during endophthalmitis, vitrectomy is an appealing adjunct to management Debridement of the vitreous cavity of bacteria, inflammatory cells, and other toxic debris; promotes better diffusion of antibiotics CLIN. MICROBIOL. REV. 2002;15(1):

78 Pyogenic bacteria Final vision acuity depends on the type of infective organism the severity of the inflammatory response and the time from onset to initiation of appropriate treatment Severe gram-negative infections with Klebsiella spp and Bacillus spp species have an especially poor visual prognosis Lancet 2004; 364:

79 Klebsiella endophthalmitis Klebsiella is a highly virulent intraocular pathogen with visual outcomes worse than counting fingers in 89% of endogenously infected eyes Symptoms of ocular inflammation usually occur within 2 to 10 days of the systemic illness, but can be delayed for serveral weeks particularly in patients with hepatobiliary infection Bilateral endophthalmitis has occurred in one quarter of all reported cases. Ophthalmology 1994;101:

80 Summary of clinical features in patients with endogenous Klebsiella pneumoniae endophthalmitis that are reported in the literature Margo Wong Yang ( ) ( ) ( ) No. of affected eyes 44(55) 16(18) 22(27) Male percentage NIDDM 27( 61%) 5(31%) 15( 68%) Liver abscess 30(68%) 10(63%) 22(100%) Bilaterality 11(25%) 2(13%) 5(23%) No. of affected eyes with 49(89%) 13(72%) 24(89%) VA worse than CF Ophthalmology 2007;114:

Chang-Sue Yang, MD, 1,2 Hsien-Yang Tsai, MD, 2,3 Chun-Sung Sung, MD, PhD, 2,4 Keng-Hung Lin, MD, 2,3 Fenq-Lih Lee, MD, 1,2 Wen- Ming Hsu, MD 1,2 1 Department of Ophthalmology, Taipei Veterans General

81 Chang-Sue Yang, MD, 1,2 Hsien-Yang Tsai, MD, 2,3 Chun-Sung Sung, MD, PhD, 2,4 Keng-Hung Lin, MD, 2,3 Fenq-Lih Lee, MD, 1,2 Wen- Ming Hsu, MD 1,2 1 Department of Ophthalmology, Taipei Veterans General Hospital, Taipei,Taiwan. 2 National Yang-Ming University School of Medicine, Taipei, Taiwan. 3 Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, Taiwan. 4 Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan. Ophthalmology 2007;114:

83 Result The diagnosis of EKE was confirmed by positive results of microbiologic culture, including blood culture in 8 patients (36%), culture of liver aspirate in 17 (77%), and vitreous culture in 11 (50%). Ophthalmology 2007;114:

84 Clinical summary of patients with endogenous klebsiella pneumoniae endopthalmitis In 10 patients (45%), ocular symptoms were the initial manifestation of Klebsiella septicemia Ophthalmology 2007;114:

85 Clinical summary of patients with endogenous klebsiella pneumoniae endopthalmitis Mean, 54.5 Male 77% NIDDM 68% 12(44%) Mean, 4d Ophthalmology 2007;114:

86 Clinical summary of patients with endogenous klebsiella pneumoniae endopthalmitis 48hr. 7 days No 1 : duration 24 hr. No 4 : duration 36 hr. No 8 : duration 2 days 22 eyes (82%) Ophthalmology 2007;114:

87 Clinical summary of patients with endogenous klebsiella pneumoniae endopthalmitis Worse outcome 24 eyes (89%) 11 eyes (41%) Evi or Enuc Ophthalmology 2007;114:

88 Discussion In 10 patients (45%) ocular symptoms were the initial manifestation of Klebsiella septicemia Despite aggressive antibiotic therapy, the final visual outcome was LP or worse in 24 eyes (89%) Successful treatment with retained useful vision better than 6/60 was achieved in only 3 eyes, of which 2 received early intravitreal corticosteroid injection Ophthalmology 2007;114:

89 Discussion The serotype K1 is also associated significantly with liver abscess and complicated endophthalmitis Diabetes is known to interfere with the chemotaxis of polymorphonuclear leukocytes. This functional abnormality in neutrophil chemotaxis and phagocytosis could contribute to increased susceptibility of infections in diabetic patients Ophthalmology 2007;114:

90 Discussion Parenteral ceftriaxone, a third generation cephalosporin with good penetration into vitreous, was the drug of choice for most patients in the current series In a rabbit model of experimental Klebsiellainduced endophthalmitis, rapid and irreversible destruction of the retinal photoreceptor occurred as early as 48 hours after infection. Ophthalmology 2007;114:

91 Discussion Intraocular steroids may have a beneficial effect on endophthalmitis with the aim of diminishing intraocular tissue destruction from the host inflammatory response (rabbit model)* The timing of dexamethasone treatment in endophthalmitis was also important (administered within 36 hours after infection, but not after 48 or 72 hours) A randomized prospective clinical trial is required to determine the efficacy of intravitreal steroids for the treatment of EKE *Ophthalmology 1991;98: Ophthalmology 2007;114:

Conclusion In the majority of patients with EKE associated with pyogenic liver abscess, visual outcome is generally poor despite aggressive antibiotic therapy.

92 Conclusion In the majority of patients with EKE associated with pyogenic liver abscess, visual outcome is generally poor despite aggressive antibiotic therapy. Early diagnosis and prompt intervention with intravitreal antibiotics within 48 hours may salvage useful vision in some patients with EKE. Ophthalmology 2007;114:

93 1 Anterior chamber 2 Cornea 3 Suspensory lig. 4 Ciliary body 5 Sclera 6 Choroid 7 Vitreous chamber 8 Optic disc 9 Retina 10 Lacrimal gland 11 Eyelid 12 Pupil 13 Iris 14 Lens

Imp. Empyema thoracis with pneumothorax Lt.

Present illness On ICD : pus 200 ml. + air Imp. Empyema thoracis with pneumothorax Lt. จ งrefer จงrefer รพ. จ งหว ด จงหวด Present illness รพ. จ งหว ด CBC : Hb 9.5 g/dl, Hct 27 % WBC 10,400 cells/mm 3 (N