Endogenous bacterial endophthalmitis masquerading as an intraocular tumor

Abstract

A 40-year-old female patient referred for a possible intraocular tumor was found to have an endogenous bacterial endophthalmitis in her right eye. Fundus examination revealed an amelanotic dome shaped choroidal mass and an exudative retinal detachment. Enhanced Depth Imaging-Optical Coherence Tomography (EDI-OCT), fundus autofluorescence (FAF) and ultrasounds were suggestive of a possible choroidal melanoma. A multimodal imaging approach and a thorough anamnesis were instrumental in establishing the correct diagnosis.

Full text

Case Report
Endogenous bacterial endophthalmitis masquerading
as an intraocular tumor
Anna Paola Salvetti
⇑
;Marco Pellegrini;Ferdinando Bottoni;Giovanni Staurenghi
Abstract
A 40-year-old female patient referred for a possible intraocular tumor was found to have an endogenous bacterial endophthalmitis
in her right eye. Fundus examination revealed an amelanotic dome shaped choroidal mass and an exudative retinal detachment.
Enhanced Depth Imaging-Optical Coherence Tomography (EDI-OCT), fundus autofluorescence (FAF) and ultrasounds were
suggestive of a possible choroidal melanoma. A multimodal imaging approach and a thorough anamnesis were instrumental in
establishing the correct diagnosis.
Keywords: EDI-OCT, Endogenous endophthalmitis, Uveal melanoma, Choroidal granuloma, Intraocular tumor
Ó2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.sjopt.2015.11.003
Introduction
Enhanced Depth Imaging-Optical Coherence Tomogra-
phy (EDI-OCT) is one of the most recent innovations for the
visualization of the retina: it allows a deeper and cross-
sectional analysis of the retina, choroid and scleral struc-
tures.
1
This adaptation has improved visualization of choroi-
dal lesions including tumors and granulomas. Additionally,
EDI-OCT can display accurately the effects of choroidal
tumors on the overlying retina and the surrounding struc-
tures. Most of the EDI-OCT tumors features are so well
depicted to allow clinicians making or excluding specific
diagnostic hypotheses.
2
Nevertheless many choroidal tumors
and granulomas share so many OCT, fundus autofluores-
cence (FAF) and fundoscopic patterns. Only a correct anam-
nesis and a multi-imaging approach support the clinician in
achieving the correct diagnosis.
Case report
A 40-year-old Caucasian female with a progressive visual
loss in her right eye from 2 weeks was referred to our institu-
tion for a possible choroidal mass involving the macula. Pre-
vious ocular and systemic medical history was unremarkable.
Upon referral, visual acuity was 20/125 in the right eye and
20/20 in the left eye and intraocular pressure was 16 mmHg
bilaterally. No inflammatory cells were present in the either
anterior or posterior chamber. Conjunctiva and sclera were
quiet. Indirect ophthalmoscopy of the right eye showed an
amelanotic, dome shaped lesion with a localized exudative
retinal detachment in the macular area and no evidence of
optic nerve edema or inflammation (Fig. 1A).
Enhanced Depth Imaging-Optical Coherence Tomography
(EDI-OCT) and fundus autofluorescence (FAF) imaging were
performed using a confocal scanning laser ophthalmoscope
Peer review under responsibility
of Saudi Ophthalmological Society,
King Saud University
Production and hosting by Elsevier
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Received 11 March 2014; received in revised form 19 May 2015; accepted 10 November 2015; available online xxxx.
Eye Clinic, Department of Clinical Science ‘‘Luigi Sacco’’, Sacco Hospital, University of Milan, Italy
⇑Corresponding author at: Eye Clinic, Department of Clinical Science ‘‘Luigi Sacco’’, Sacco Hospital, University of Milan, via G.B. Grassi 74, 20100
Milano, Italy. Tel.: +39 3397473737.
e-mail address: paola.anna.salvetti@gmail.com (A.P. Salvetti).
Saudi Journal of Ophthalmology (2015) xxx, xxx—xxx
Please cite this article in press as: Salvetti A.P., et al. Endogenous bacterial endophthalmitis masquerading as an intraocular tumor. Saudi J Ophthalmol (2015),
http://dx.doi.org/10.1016/j.sjopt.2015.11.003

(HRA+OCT Spectralis, Heidelberg Engineering GmbH,
Heidelberg, Germany). EDI-OCT examination of her right
eye confirmed the presence of a choroidal mass with smooth
dome-shaped surface and inward compression of the choroi-
dal vascular structures (Fig. 1B). The overlying retina had no
visible intraretinal infiltration. A serous retinal detachment
and scattered retinal pigment epithelium (RPE) irregularities
could be identified over the lesion. The choroidal infiltrate
was unifocal with an intense shadowing precluding the
identification of the sclerochoroidal interface.
FAF showed a granular pattern with irregular areas of
hyper and hypo-fluorescence likely indicating a greater meta-
bolic activity of the RPE cells occurring before cells death
3
(Fig. 1C). A and B-scan ultrasonography showed a dome
shaped choroidal lesion acoustically hollow due to low-
medium internal reflectivity.
On the basis of these imaging characteristics main differ-
ential diagnosis included a possible neoplastic etiology (ame-
lanotic choroidal melanomas, choroidal metastasis, choroidal
hemangiomas or choroidal lymphomas) or a granuloma.
EDI-OCT exam was instrumental in achieving the correct
diagnosis. EDI-OCT in choroidal hemangiomas typically
shows a diffuse choroidal thickening whereas our patient dis-
plays significant compression of the inner and outer choroid
with no compression of the choriocapillaris. Moreover at fun-
dus examination the lesion was yellow in color and character-
ized by imperceptible margins (Fig. 1A) whereas choroidal
hemangiomas are typically orange or red with more defined
boundaries.
4
The inner surface of the mass appeared smooth
in its shape in contrast to the placid, rippled or seasick pat-
tern of choroidal lymphomas
5
and the ‘‘lumpy-bumpy’’
appearance of choroidal metastasis.
6
Moreover choroidal
lymphomas are sometimes associated with ocular adnexal
disease and patients tend to be older. Metastasis is often
bilateral and multifocal and the patient often has a known
history of primary malignancy.
Ultrasonography is helpful in differentiating this diagnosis
with higher internal echogenicity such as choroidal heman-
giomas compared to choroidal melanomas.
Fluorescein angiography (FA) and indocyanine green
angiography (ICG) were contributory to rule out the hypoth-
esis of a neoplastic etiology. ICG, in particular depicted a
mass obscurating the choroidal vascular network with no
intrinsic vascularization (Fig. 1D). FA showed no perfusion
of the choriocapillaris likely due to a compression by the
lesion itself and optic disk hyperfluorescence in late phases
of the exam (Fig. 1E). No staining or pinpoint leakage at
the level of the retinal pigment epithelium (RPE) was
observed.
7
A more comprehensive medical history was collected,
revealing a dental extraction performed 10 days before the
onset of symptoms, with subsequent fever and a moderate
enlargement of the latero-cervical lymph nodes.
On the basis of the anamnesis and clinical features a diag-
nosis of stage 1 endogenous bacterial endophthalmitis with
focal chorioretinal infiltration and no extension into the vitre-
ous cavity
8
was made.
In agreement with our Infectious Diseases Department we
immediately started an empirical aggressive treatment with
Amoxicillin/Clavulanate 875 mg/125 mg 3 times/day for
10 days. Meanwhile, a complete blood workup, electrophore-
sis, study of erythrocyte sedimentation rate (ESR), C-reactive
protein (CRP), antinuclear antibodies (ANA), extractable
nuclear antigens (ENA), DNA antibody (anti-dsDNA),
Figure 1. Baseline visit. (A) Fundus photography showing a yellow choroidal mass with imperceptible margins. (B) Enhanced Depth Imaging-Optical
Coherence Tomography (EDI-OCT) displaying a choroidal mass with inward compression of the choroidal vascular structures, a smooth dome shaped
appearance of the retina, subretinal fluid and no visible retinal infiltration. The mass shadowing precludes identification of the sclerochoroidal interface.
(C) Fundus Autofluorescence (FAF) imaging showing a granular pattern with areas of hypo and hyper autofluorescence. (D–E) Indocyanine green and
fluorescein angiography examinations (ICG and FA) confirming the presence of a choroidal mass obscuring the choroidal vascular network with no
intrinsic vascularization. (D) FA confirmed non-perfusion of the choriocapillaris in the macular area and displayed late optic disk hyperfluorescence (E).
2 A.P. Salvetti et al.
Please cite this article in press as: Salvetti A.P., et al. Endogenous bacterial endophthalmitis masquerading as an intraocular tumor. Saudi J Ophthalmol (2015),
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complement component C3 and C4 and an echocardiography
were performed. Blood tests were considered normal except
for an active endocarditis at echocardiography. Within 3 days
since the beginning of systemic treatment, ophthalmoscopy
and EDI-OCT examinations showed the choroidal mass signif-
icantly reduced in size with complete resolution at 1 month
(Fig. 2A–B). Visual acuity was completely restored after
3 months despite the persistence at OCT of ellipsoid, outer
segment of photoreceptor and RPE layer defects (Fig. 2B).
FAF showed persistence of a granular pattern (Fig. 2C). ICG
examination showed disappearance of the choroidal infiltra-
tion whereas FA displayed a normal perfusion of the chorio-
capillaris and the resolution of the hot disk (Fig. 2D–E).
Discussion
Our case stresses the importance of a multi-imaging
approach and an accurate medical history collection in
managing a patient with a choroidal lesion. Choroidal
abscess is an extremely rare presentation of endogenous
bacterial endophthalmitis. The rarity is further enhanced by
the infrequency of endogenous bacterial endophthalmitis
itself, which accounts for only 2–6% of all endophthalmitis
cases.
8–11
Previous reports have made distinctions in focal
bacterial infections involving the retina or the choroid: cases
of subretinal abscess
12–15
, intraretinal abscess
16
, septic retinal
cyst
17
and choroidal abscess have been described.
18–20
.
40% of endogenous endophthalmitis in the USA are due to
endocarditis, usually caused by Staphylococcus aureus and
Streptococci.
10
Cases of metastatic bacterial choroidal absc-
esses caused by S. aureus in patients with endocarditis have
been reported by other authors.
19,20
The lesions have been
described as discrete yellow or white choroidal foci, and
although they may be sterilized with systemic antibiotic ther-
apy, they may be associated with choroidal neovascularization
requiring laser treatment
19,20
or now intravitreal injections.
Ophthalmologists should be aware of this entity since 43%
of patients with endogenous endophthalmitis have no extra-
ocular symptoms.
9
A prompt recognition of the pathology
increases the rates of visual function recovery and prevents
possible systemic dissemination.
In conclusion, we described a case of stage 1 endogenous
endophthalmitis.
21
To our knowledge, this is the first EDI-
OCT description of this condition. EDI-OCT examination dis-
played a dome shaped choroidal mass with low-medium
internal reflectivity and discrete shadowing of the sclero-
choroidal interface. The absence of an intrinsic vasculariza-
tion was confirmed by FA and ICGA examination.
Conflict of interest
The authors declared that there is no conflict of interest.
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Please cite this article in press as: Salvetti A.P., et al. Endogenous bacterial endophthalmitis masquerading as an intraocular tumor. Saudi J Ophthalmol (2015),
http://dx.doi.org/10.1016/j.sjopt.2015.11.003