Accepted Manuscript Title: Bacillus cereus panophthalmitis associated with injection drug use Author: Nilay Kumar Neetika Garg Nilesh Kumar Nicholas Van Wagoner PII: DOI: Reference:
S1201-9712(14)00056-3 http://dx.doi.org/doi:10.1016/j.ijid.2014.01.019 IJID 1902
To appear in:
International Journal of Infectious Diseases
Received date: Revised date: Accepted date:
23-10-2013 18-1-2014 20-1-2014
Please cite this article as: Nilay KumarNeetika GargNilesh KumarNicholas Van Wagoner Bacillus cereus panophthalmitis associated with injection drug use (2014), http://dx.doi.org/10.1016/j.ijid.2014.01.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Running heads: Recto: Bacillus cereus panophthalmitis
Correspondence footnote: *Corresponding author.
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E-mail address:
[email protected] (N. Kumar).
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Verso: N. Kumar et al.
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[ARTICLE TYPE – CASE REPORT]
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Bacillus cereus panophthalmitis associated with injection
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drug use
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Nilay Kumara,*, Neetika Gargb, Nilesh Kumarc, Nicholas Van Wagonerd
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Department of Medicine, Cambridge Health Alliance, Harvard Medical School, 1493
Cambridge St, Cambridge, MA 02139, USA b
Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical
School, Boston, Massachusetts, USA
c
Department of Medicine, Manipal University, Manipal, Karnataka, India
d
Division of Infectious Diseases, Department of Medicine, University of Alabama at
Birmingham, Birmingham, Alabama, USA
[Received date] Corresponding Editor: Eskild Petersen, Aarhus, Denmark
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KEYWORDS Bacillus cereus;
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Endophthalmitis; Injection drug use;
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Panophthalmitis
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Summary
We report a case of rapidly progressive vision loss in a young woman with a history
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of injection drug use. Subsequent enucleation of the affected eye was done and Bacillus cereus grew on tissue culture. B. cereus is a rare cause of endogenous
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Introduction
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injection drug use.
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endophthalmitis due to hematogenous seeding of the vitreous in the setting of
[Au?1]
Case report
An 18-year-old Caucasian woman with a history of intravenous drug abuse presented with a severe left-sided frontal headache followed by left-sided peri-orbital pain, redness, and swelling for 1 week. Symptoms began as a mild headache, which progressed to swelling and redness of the left eye, decreased visual acuity, and severe pain on eye movement within 2–3 days. Evaluation at another facility 2 days prior to
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presentation was suggestive of endophthalmitis, and treatment with intravenous vancomycin and piperacillin–tazobactam was initiated. In the following 48 h her symptoms progressed relentlessly to complete vision loss in the left eye, prompting
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transfer to our tertiary medical center. She smoked marijuana and used methamphetamines, occasionally sharing needles for injection drug use. The most
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recent episode of injection drug use was 1 week prior to admission.
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On examination, there was left eye proptosis with peri-orbital swelling,
erythema, and exquisite tenderness to palpation. There was no light perception in the
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affected eye. Marked sinus tenderness was noted. Routine laboratory tests showed a white blood cell count of 18 × 109/l [Au?2] with 86% neutrophils; serology for HIV 1
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and 2 was negative. A tomography scan of the orbits showed proptosis and enlargement of the left globe, with circumferential scleral enhancement (Figures 1 and
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2). There was no evidence of cavernous sinus thrombosis. Initial differential
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diagnoses included polymicrobial aerobic/anaerobic infection,
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staphylococcal/streptococcal infection, mucormycosis, and invasive aspergillosis.
[Figures 1 and 2 here]
Intravenous vancomycin and piperacillin–tazobactam were continued. An
emergent ophthalmology consult was obtained. Given the progressive nature of the infection despite antibiotics and the potential for intracranial spread of the infection, an urgent enucleation with peri-orbital tissue debridement was performed. Gram stain of the ocular tissue showed abundant Gram-positive rods and tissue culture grew Bacillus cereus. She completed 12 days of treatment with intravenous vancomycin
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and was discharged on oral ciprofloxacin to complete 6 weeks of antibiotic treatment. She was doing well at follow-up 3 months after discharge.
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Discussion
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Infectious complications are common among injection drug users (IDUs).
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Staphylococcus aureus, Streptococcus, and Gram-negative rods are commonly implicated in such infections. An increasing number of reports have described
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Bacillus species as pathogens in IDUs.
B. cereus is a ubiquitous, motile, endospore-forming, Gram-positive rod. It is
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perhaps best known as a cause of food poisoning associated with the consumption of stale fried rice and is often regarded to be a ‘non-pathogenic’ contaminant when
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isolated in other settings. Rare cases of B. cereus meningitis, endocarditis, and
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septicemia have been reported in high-risk patients with acute leukemia and other immunodeficiency states.1
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Exogenous endophthalmitis due to B. cereus is relatively common in the
setting of traumatic globe injuries,1 however reports of endogenous endophthalmitis due to B. cereus in association with injection drug use are rare.2–4 These infections are extremely fulminant with rapid progression to panophthalmitis and loss of light perception within hours of intraocular inoculation. The pathogenesis of ocular infections in IDUs involves transient bacteremia and lodging of infectious emboli in the retinal and ciliary arterioles. B. cereus is a highly virulent organism due to the production of enzymes lecithin, hemolysins, and phospholipase C, resulting in rapid tissue destruction.1 Expedited treatment with intravenous vancomycin, aminoglycosides, or
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fluoroquinolones is the treatment of choice.1–4 Systemic antibiotics are indicated in all cases of endogenous endophthalmitis due to B. cereus. In cases of exogenous B. cereus endophthalmitis, as in the case of traumatic globe injuries, intravitreal
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antibiotics including vancomycin and ceftazidime are indicated with or without vitrectomy.5
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Despite adequate treatment, outcomes are typically poor, resulting in complete vision loss, phthisis bulbi, or enucleation. There were 35 cases of B. cereus eye
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infection reported in the 20th century, of which 70% resulted in vision loss due to
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enucleation.1
In conclusion, we have described a case of fulminant B. cereus
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panophthalmitis with irreversible vision loss associated with injection drug use. Internists and infectious disease specialists should remain cognizant of ocular B.
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decreased visual acuity.
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cereus infections when evaluating IDUs with retro-orbital headaches, eye pain, or
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Conflict of interest: The authors have no conflicts of interest to report.
References
1.
Drobniewski FA. Bacillus cereus and related species. Clin Microbiol Rev 1993;6:324–38.
2.
Hatem G, Merritt JC, Cowan CL. Bacillus cereus panophthalmitis after intravenous heroin. Ann Ophthalmol 1979;11:431–40.
3.
Shamsuddin D, Tuazon CU, Levy C, Curtin J. Bacillus cereus panophthalmitis: source of the organism. Rev Infect Dis 1982;4:97–103.
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4.
Young EJ, Wallace RJ, Ericsson CD, Harris RA, Clarridge J. Panophthalmitis due to Bacillus cereus. Arch Intern Med 1980;140:559–60. Durand ML. Endophthalmitis. Clin Microbiol Infect 2013;19:227–34.
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5.
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Figure captions
Figure 1 Coronal reconstructed contrast-enhanced computed tomography image
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enhancement of the sclera suggestive of panophthalmitis.
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showing significant enlargement of the left globe along with diffuse contrast
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Figure 2 Sagittal [Au?3] reconstructed contrast-enhanced computed tomography image showing significant enlargement of the left globe along with diffuse contrast
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enhancement of the sclera suggestive of panophthalmitis.
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Figure 1
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Figure 2
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