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<Chief
complaint>
Abdominal pain, diarrhea and fever for ten days.
<Brief
history>
This 73-year-old male patient, a case of diabetes mellitus
(DM) for 20 years without regular medical control, has
suffered from diarrhea and abdominal pain since July 10, 1999.
He took some medication to relieve the pain. However, diarrhea
about 2-3 times a day persisted. His stool was loose, neither
bloody nor mucoid and was accompanied by low abdominal
cramping pain. He did not pay much attention to it since the
diarrhea was not very severe. Nevertheless, severe chills and
high spiking fever developed in the afternoon of July 17. His
fever subsided after he taking some antipyretics. However,
progressive abdominal pain, diarrhea and fever relapsed and he
came to the emergency room on July 19, where lower abdominal
cramping pain, equivocal bloody and mucoid stool, leukocytosis
with left shift were noted. Cefotiam was administered
empirically under the impression of diverticulitis. Abdominal
sonography showed wall thickening in the rectosigmoid colon.
General surgeon was consulted and colonoscopy or abdominal
computed tomography (CT) was suggested. Abdominal and pelvic
CT showed wall thickening in the rectosigmoid colon without
hollow organ perforation. The abdominal pain, diarrhea and
fever improved gradually with antibiotics, but blurred vision
occurred on July 21. Ophthalmological examination showed that
his visual acuity was only of counting finger/ 50 cm (od).
Proliferative diabetic retinopathy (PDR) (od) with macular
hemorrhage was also diagnosed and Fluorecein anigiography
(FAG) was performed on July 22, which revealed vitreous
hemorrhage and transamin was administered for hemostasis.
Colonoscopy performed on July 23 showed 4-5 mass lesions with
hyperemia, small holes and pus in rectum and rectosigmoid
junction and a polyp at upper rectum. Biopsy and culture were
done. Under the suspicion of diverticulitis or amebic colonic
abscess, he was admitted on July 23.
<Physical
examination>
The consciousness was clear. The blood pressure was 157/91
mmHg, body temperature was 36.8°C, pulse rate was 85/min, and
respiratory rate was18/min. Conjunctiva was not pale,
anicteric sclera, clear breath sound and regular heart beat
without murmur were noted.
There was distended abdomen with hypoactive bowel sound,
tenderness and rebound tenderness.over lower abdomen. Muscle
guarding was also noted. Liver and spleen were both
impalpable.
<Laboratory
data>
|
WBC |
RBC |
Hb |
MCV |
Plat |
Seg |
Eos |
Baso |
Mono |
Lym |
|
/ul |
106/ul |
G/dl |
fl |
103/ul |
% |
% |
% |
% |
% |
|
9430 |
4.10 |
13.0 |
92.0 |
53k |
92.0 |
0.3 |
0.1 |
3.4 |
4.2 |
|
A/G |
Bil(T/D) |
AST |
ALT |
ALP |
r-GT |
BUN |
Cre |
Amy |
Lip |
Na |
K |
Ca |
|
g/L/g/L |
mg/dl |
U/L |
U/L |
U/L |
U/L |
mg/dl |
mg/dl |
U/L |
U/L |
mM |
mM |
mM |
|
2.8/3.5 |
1.3 |
39 |
43 |
223 |
168 |
20 |
1.1 |
<46 |
102 |
137 |
4.3 |
2.07 |
|
PT |
PTT |
Glu.AC |
|
sec |
sec |
mg/dl |
|
12.3/11.2 |
36.9/33.9 |
306 |
Urinalysis: negative
Stool : occult-blood (+/-),
pus cell (-)
Stool
culture: No Salmonella, Shigella,
Campylobacter, Clostridium
Colonoscopic
abscess culture:
no pathogen, many neutrophil.
Biopsy: no malignant cell,
polyp
IHA
test: 8x (-)
Vitreous culture &
smear:
no pathogen
Vitreous culture &
smear: numerous PMN
<Image
study>
Abdominal
Ultrasonography;
Colonic wall thickening
over rectosigmoid junction, fatty liver, fat-free area of the
liver.
CT of Abdomen &
pelvis:
Long segmental narrowing and wall
thickening of the rectum and sigmoid colon. There is dirty fat
plane at mesosigmoid colon. This may be inflammatory change or
neoplastic process of the rectosigmoid colon.
Colonoscopy:
There were 4-5 submucosal masses with hyperemia, and small
holes with pus in rectum and rectosigmoid junction. Other
areas of the rectum were edematous. A polyp at upper rectum
and multiple inflammatory masses in the rectum and
rectosigmoid junction were found and biopsy for pathology and
culture was performed. Diverticulitis or ameba was suspected.
<Course and
treatment>
After admission, intravenous cefoxitin was administered
empirically, and the bowel symptoms and the fever improved.
However, ophthalmological examination of the right eye on the
admission showed 4+ cells in the anterior chamber. The fundus
was obscured because of dense vitreous opacity. His visual
acuity was of hand movement at 30 cm. There was 3+ chemosis
but the extraocular muscle movement was full and free.
Vitreous paracentesis was done and amikacin and vancomycin
were injected intravitreously on July 24. Culture of the
specimen yielded no pathogen. His vision improved initially
but became deteriorated gradually. Pars plana vitrectomy and
intravitreous injection of vancomycin and amikacin were done
on July 29. Ceftriaxone was administered instead to provide a
more effective blood-retina barrier penetration. Elevated
intraocular pressure and eye pain were noted, and cryotherapy
was performed on August 6 to decrease the intraocular
pressure. He was transferred to Ophthalmological department
for further care. Trans-sclera cyclophotocoagulation (TSCPC)
was done on Aug 16 due to persistent eye pain and elevated
intraocular pressure. The eye pain subsided but he became
totally blind in the right eye. He was discharged on Aug 28
and followed at OPD.
<Discussion>
眼內炎（endophthalmitis）是定義為眼內液及眼內組織的發炎。而如果引起的原因為微生物感染，則最後常常造成嚴重視力減退，甚至失明。
眼內炎可分為
1. 眼科手術後眼內炎；
2.
創傷後眼內炎；
3.
內源性眼內炎三類。
這樣分類的好處可用以預測致病微生物及培養確認前的抗生素使用。前二類多為革蘭氏陽性菌，第三類多為革蘭氏陰性菌。
約70%的眼內炎是屬於眼科手術後眼內炎，25%是創傷後眼內炎。內源性眼肉炎佔不到5%，是其中最不常見的，然而值得注意的是罹患內源性眼內炎的病患大多是免疫力差或者是靜脈藥物濫用的患者。
臨床上診斷眼內炎可分為兩部分：一是臨床症狀，一是微生物確認。臨床症狀方面包括視力減退、紅眼、眼痛、明顯的眼內發炎症候（包括hypopyon，conjunctival
congestion及corneal haze）。微生物確認必須做vitrectomy取得眼內液，可放在culture
media或blood culture瓶送檢。
內源性眼內炎的特色是發生時程快（acute onset），進展很快（rapid
progression）及對抗生素反應差（refractory response）。宿主因子則常常和糖尿病（diabetes
mellitus）有關。在台灣第一名的致病菌是克雷白氏菌（Klebsiella
pneumoniae）。若以原發器官論，則以腸道感染原預後為最差。所以，只要一發現，盡快做致病菌的確認以及給予適合的抗生素是唯一方針。但即使如此，失明的機會仍然很高。
<Reference>
1.
Zentralbl Bakteriol. 1997 Feb;285(3):341-67. Review.
2.
Arch Intern Med. 1991 Aug;151(8):1557-9.
3. Surv
Ophthalmol. 1986 Sep-Oct;31(2):81-101. Review.
4. Int
Ophthalmol Clin. 2004
Fall;44(4):115-37.
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Case Discussion
繼續教育考題