Endogenous Klebsiella Endophthalmitis with Unknown Primary Origin-A Case Report

身體原發感染病灶之克雷白氏肺炎桿菌內因性眼內炎－病例報告

林純如(Chun-Ju Lin) ； 林昌平(Chang-Ping Lin) ； 楊中美(Chung-May Yang)

《中華民國眼科醫學會雜誌》 42卷3期 (2003/09) Pp. 218-222

https://doi.org/10.30048/ACTASOS.200309.0008

摘要

目的：本篇報告一例非糖尿病息者罹患不明身體原發感染病灶之克雷白氏肺炎桿菌內因性眼內炎，雖經積極治療，右眼病程仍惡化，但左眼與身體無出現明顯感染病灶。
方法：病例報告。
結果：病人為五十七歲女性，無糖尿病、眼部手術及外傷病史，因右眼視力忽然模糊至急診就醫；右眼視力僅能辨手動，細隙燈檢查發現右眼前房有嚴重的炎性反應，虹膜完全後黏連。右眼超音波顯示嚴重的玻璃體混濁。理學、神經學、及抽血檢查皆在正常範圍內。頭部及眼窩電腦斷層，肝臟及心臟超音波皆無異常發現。右眼玻璃體抽取液經革蘭氏染色發現革蘭氏陰性桿菌，培養長出克雷白氏肺炎桿菌。我鎵－67全身掃描檢查只有在右眼部有鎵－67攝取增加的現象。整個病程左眼沒有眼內炎的跡象。雖經積極治療，發病一個月後右眼視力無光覺，但左眼與身體無出現明顯感染病灶。
結論：我們報告此病例，希望提醒大家克雷白氏肺炎桿菌內因性眼內炎，亦可能發生在非糖尿病患者，或是沒有其他明顯身體感染的病人。在台灣由於抗生素的濫用，克雷白氏肺炎桿菌引起的菌血症有增加的趨勢，已經成為公共衛生重視的問題。醫師與民眾必須小已使用抗生素，以免造成腸內菌種產生抗藥性，一旦腸道黏膜有微小的傷口，就可能因為具抗藥性的細菌進入血液，由菌血症導致內因性眼內炎。此病例可能因為腸道黏膜傷口太過微小，以至於包括－67全身掃描在內的詳細檢查仍找不到身體原發感染病灶，必需藉由眼科醫師臨床的高度警覺來診斷內因性眼內炎。不明身體原發感染病灶之克雷白氏肺炎桿菌內因性眼內炎病程可能病程惡化快速，必須與非感染性葡萄膜炎等其他疾病小心鑑別診斷，及時選擇適當的抗生素治療，以挽救視力，同時避免其他身體器官的感染。

並列摘要

Purpose: To report a non-diabetic patient with endogenous Klebsiella endophthalmitis of unknown infectious focus and to describe the fulminant course despite aggressive therapy.
Method: Case report.
Results: A 57-year-old non-diabetic woman without significant past medical history presented to the emergency department complaining of loss of vision OD for 1 day. Her best-corrected visual acuity was hand motion OD and 25/20 OS. A slit-lamp examination showed fibrin and inflammatory cells in the anterior chamber, and 360° posterior synechiae OD. B-scan ultrasonography showed dense vitreous opacity OD. General physical, neurological examinations and pertinent laboratory studies were all within normal limits. Computed tomogram of the head and orbits and ultrasound of the liver and heart were non-contributory. A right vitreous biopsy for culture, intravitreal antibiotic injection and pars plana vitrectomy were performed. Gram-stained smears revealed Gram-negative rods, and cultures yielded Klebsiella pneumoniae. A Gallium-67 whole body survey showed intense Ga-67 activity accumulation only in the right eye region. Despite aggressive treatment, vision still declined to no light perception. No other signs of sepsis developed. The left eye was not involved.
Conclusion: This case shows that Klebsiella endophthalmitis may occur even in patients without diabetes or obvious systemic infection. In Taiwan, community-acquired Klebsiella pneumoniae bacteremia has emerged as substantial public health problem. It’s important to educate doctors and patients not to abuse antibiotics. Familiarity with endogenous Klebsiella endophthalmitis would aid in early differentiation from noninfectious uveitis and institution of appropriate antibiotic therapy.

並列關鍵字

Endogenous endophthalmitis ； Klebsiella pneumoniae