Pseudomonas-induced bilateral endophthalmitis with corneal perforation in a neonate.

Neonatal endophthalmitis is a rare entity that may be exogenous or endogenous. Pseudomonas aeruginosa is a ubiquitous gram-negative rod that may appear as a nosocomial source of infection in the neonatal intensive care unit. A case of bilateral Pseudomonas-induced endophthalmitis is presented, and a discussion of the case and of the relevant literature follows. CASE REPORT A male infant was born at 24 weeks’ gestational age by cesarean delivery resulting from vaginal bleeding and prolonged rupture of membranes. The baby weighed 736 g and had Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. An evaluation for sepsis was performed, and the baby was prophylactically given ampicillin and gentamicin. The baby was intubated as a result of respiratory distress. The findings from cultures were negative, and antibiotics were discontinued after 7 days. Two weeks later, the neonate had increasing oxygen requirement and carbon dioxide retention while still intubated. A second evaluation for sepsis was performed. Radiographic findings were suggestive of necrotizing enterocolitis, and the patient was again given ampicillin and gentamicin. The results of blood cultures were negative, and the baby’s status improved with no further signs of necrotizing enterocolitis. The antibiotics were discontinued after 72 hours. One week later, the baby’s general status deteriorated again, with pallor, decreased spontaneous activity, and worsening arterial blood gases on increasing ventilator settings. A third set of blood cultures was performed, and again the results were negative. This time, the baby was empirically given vancomycin and gentamicin. After initial improvement, the baby became unstable. Blood cultures, performed for the fourth time in 4 weeks, now revealed P aeruginosa. Pediatric infectious disease consultation was obtained, and ceftazidime was substituted for vancomycin. An ophthalmology consultation was requested for a newly noted discharge and “cystic lesion” between the left eyelids. This was 2 days after the first positive blood culture (after 4 weeks and 3 negative blood cultures), and 8 days after restarting antibiotics. Ophthalmic examination revealed mucopurulent discharge from both eyes (Figure 1). The right eyelids were mildly edematous. The perilimbal bulbar conjunctiva of the right eye appeared avascular, and the underlying sclera appeared thin. The right cornea was intact and clear but was diffusely and extremely thinned. The right anterior chamber was formed, and there was no hypopyon. The iris and pupil were normal, and the lens was clear. A folded white retrolenticular mass was suggestive of a total retinal detachment. Examination of the left eye revealed the crystalline lens protruding through the palpebral fissure. A carefully placed lid speculum enabled further examination of the left eye (Figure 2). The left conjunctiva was also avascular, and the cornea was perforated with the intraocular contents prolapsed out. A conjunctival culture was performed on the right eye that grew P aeruginosa. Followup examination the next morning revealed a perforated right cornea with a flat anterior chamber. Further workup could not be performed because of the baby’s systemic instability. The child died the next day as a result of an overwhelming sepsis. The family declined a request for autopsy. DISCUSSION