Case Study
Chronic Endophthalmitis Caused by Propionibacterium acnes: A Clinicopathologic Report
Andrew A. Kao, MD • Darlene Miller, DHsc • Sander R. Dubovy, MD • Harry W. Flynn, Jr., MD
Chronic or delayed-onset postoperative endophthalmitis is
characterized by persistent low-grade inflammation, often with a latent
onset worsening over months.
3-6 Although estimated to be less
common than acute-onset endophthalmitis, the true incidence of chronic
endophthalmitis is still not known.
5 In one single-center series, the reported rate of chronic postoperative endophthalmitis following cataract surgery was 0.017%.
6
Propionibacterium acnes is an anaerobic, gram-positive
pleomorphic bacillus found in the skin and hair follicles of normal
individuals and is known to cause both acute-onset and delayed-onset
postoperative endophthalmitis.
2-5,7 We present a
post–cataract surgery patient with chronic recurrent endophthalmitis and
microbiologic confirmation and histopathologic correlation of
P. acnes infection.
CASE REPORT
A 68-year-old woman underwent uncomplicated cataract surgery with
placement of a posterior-chamber IOL in her left eye in September 2009.
She presented two months later with mild reduction in vision and
moderate anterior-chamber cells that responded to topical steroids. Upon
tapering the steroids, the inflammation returned.
Four months after cataract surgery (January 2010), a pars plana
vitrectomy was performed, and intravitreal vancomycin and ceftazidime
were prescribed. Cultures were positive for vancomycin-sensitive
Staphylococcus epidermidis and
Corynebacterium
species. Upon tapering postoperative topical steroids, the inflammation
returned, but her visual acuity remained 20/25 in the left eye. She was
referred to our center at this point for consultation. The differential
diagnosis included infectious endophthalmitis caused by fungi or by
P. acnes vs a lens-material–induced chronic inflammation. Moxifloxacin and prednisolone drops were continued.
She was observed for the next four months, when she presented in May
2010 with recurrent inflammation, pain and redness of the left eye. On
examination, her visual acuity was 20/40, and slit-lamp examination
disclosed multiple progressive keratic precipitates and a hypopyon (
Figure 1).
The antibiotics and steroids were increased, and the hypopyon resolved
with a reduction in the inflammation. The medications were slowly
tapered.
Figure 1. A slit-lamp photograph of the left eye demonstrates
keratic precipitates (KPs) prior to pars plana vitrectomy. These KPs
resolved after treatment.
In June 2010, she returned with a visual acuity of 20/30 OS, a
recurrent hypopyon and 2+ vitreous cells. A pars plana vitrectomy with
intraocular lens removal was performed and intravitreal injections of
vancomycin and dexamethasone were given. Histologic examination of the
specimen disclosed lens capsule, cortical lens material, lens
epithelium, and metaplastic fibrocellular tissue, with a moderate amount
of gram-positive coccobacilli present within the tissue (
Figure 2a). Cultures of the capsular bag contents in a thioglycollate broth and on anaerobic blood agar were positive for
P. acnes (
Figure 2b).
At one month after treatment, the keratic precipitates resolved, and
visual acuity improved. At the six-month follow-up (January 2011), the
best-corrected visual acuity was 20/25 using an aphakic contact lens for
the left eye.
Figure 2a. Propionibacterium acnes organisms within the capsular bag. Brown & Hopps Gram stain, 1000x magnification. Arrowheads = lens capsule, asterisk = P. acnes organisms.
Figure 2b. A photograph of an anaerobic blood agar plate demonstrates yellow-tan colonies typical of P. acnes growth.
DISCUSSION
The findings of chronic
P. acnes endophthalmitis are often
subtle, and these patients may lack the severe pain, poor vision and
hypopyon often seen in acute-onset endophthalmitis.
3,5,7 The classic clinical sign of
P. acnes
endophthalmitis is the presence of a white, creamy, intracapsular
plaque that consists of peripheral lens cortex and sequestered
organisms, as was noted in our patient.
3-5,7 The inflammation
may initially respond to topical steroids but often recurs with steroid
tapering. Definitive diagnosis is achieved by Gram stain of the
specimen and anaerobic cultures are necessary to confirm growth.
Anaerobic cultures should be held for at least one to two weeks, as
P. acnes is a slow-growing organism.
1-5,7 Polymerase chain reaction may also be used to identify the organism in cases with negative smears and cultures.
5,8
Initial treatment with intravitreal antibiotics may achieve transient
improvement, but is associated with a high rate of recurrence.
2-5,7 Curative treatment may involve vitrectomy and complete removal of the capsular bag and IOL removal or exchange.
3,7 Resolution of KPs follows surgical treatment and is a clinical marker of infection resolution.
9 The visual prognosis of chronic
P. acnes endophthalmitis is generally more favorable than acute-onset postoperative endophthalmitis caused by more virulent organisms.
1-2 RP
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Treatment strategies and visual acuity outcomes in chronic
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Ophthalmic Surg Lasers Imaging. 2010:1-3. doi: 10.3928/15428877-20100215-61. [Epub ahead of print]