Introduction

Endogenous endophthalmitis is a rare, serious complication of bacteraemia, with a prevalence of 2–8% of all cases of endophthalmitis [1]. Diagnosis is frequently delayed, with a poor prognosis. In many patients it is associated with underlying medical conditions known to predispose to infection, such as diabetes mellitus, cardiac disorders and malignancy [1]. Rare cases of postpartum endogenous Candida endophthalmitis have been described [2, 3]. We describe a case of endogenous bacterial endophthalmitis (EBE) in a healthy, pregnant female who developed ocular symptoms at the time of delivery.

Case report

A 26-year-old Asian woman (para 3) had an uncomplicated pregnancy until premature rupture of membranes (PROM) at 35 weeks, when she was admitted to hospital. A high vaginal swab culture grew group B streptococci. She was prescribed oral phenoxymethylpenicillin but refused to take it. She developed mild fever and malaise 2 days prior to the delivery. Blood cultures were not taken but this resolved immediately postpartum without treatment.

Spontaneous labour began at 36 weeks’ gestation. She had a normal vaginal delivery of a healthy baby but sustained a superficial perineal laceration. The baby had a septic work-up but all cultures were negative.

The patient presented to us with a 3-week history of visual deterioration and pain in the right eye. These symptoms began one day after delivery. There was no history of previous ocular trauma or surgery. She had been treated for the last 3 days at the local eye clinic for panuveitis of unknown aetiology. She was taking oral prednisolone 30 mg o.d., g. maxidex 6 times per day and g. cyclopentolate 1% b.d. to the right eye. Visual acuity (VA) and pain rapidly worsened after 48 h of treatment.

VA was light perception (with poor projection) OD and 6/6 OS. There was no relative afferent pupil defect. There was marked right anterior chamber (AC) inflammation with posterior synechiae and a sliver of hypopyon. A dense fibrin membrane covered the pupil which precluded fundus examination. A B-scan ultrasound showed dense vitritis but no evidence of retinal pathology (Fig. 1). Examination of the left eye was normal.

Fig. 1
figure 1

A B-scan ultrasound of the patient’s right eye at presentation showing dense vitritis and posterior vitreous detachment

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Investigations included a full blood count, urea and electrolytes, erythrocyte sedimentation rate, C-reactive protein, serum angiotensin converting enzyme, syphilis and toxoplasmosis serology, autoimmune screening, hepatitis B and human immunodeficiency virus tests, HLA-B51, blood cultures and chest X-ray which were normal.

The steroids were increased to 80 mg o.d. There was less AC activity and fibrin after 3 days but no improvement in posterior segment signs. Viral retinitis was suspected so a vitreous tap was performed and intravitreal foscarnet was injected (2.4 mg/0.1 ml). Oral valacyclovir 1 g t.d.s. was commenced pending polymerase chain reaction (PCR) of the vitreous biopsy.

There was no improvement 3 days later. PCR was negative for the viruses CMV, HSV, VZV and EBV but bacterial culture grew coliform species, Sphingomonas paucimobilis (sensitive to ciprofloxacin, gentamicin and vancomycin). A second vitreous tap was attempted but no sample was aspirated; intravitreal antibiotics were injected (amikacin 0.4 mg/0.1 ml and vancomycin 2.0 mg/0.1 ml). Three days later the pain had greatly reduced, the conjunctival injection was less marked and the hypopyon had cleared.

Oral moxifloxacin 400 mg o.d. was given for 4 weeks. The topical and systemic corticosteroids were gradually tapered over 3 months. She underwent right cataract surgery 8 months later (Fig. 2, left). Visual acuity was 6/9 OD post-operatively. The eye remained quiet but examination of the fundus showed slight optic disc pallor and mild peripapillary fibrosis (Fig. 2, right).

Fig. 2
figure 2

Left Anterior segment photograph a few months after presentation shows a dense posterior subcapsular cataract in the right eye and evidence of broken posterior synechiae on the anterior capsule of the lens. Right Fundus photograph of the right eye (after cataract surgery) shows optic disc pallor and adjacent fibrosis

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Discussion

Genital tract infection is a significant risk factor for PROM and predisposes to chorioamnionitis and maternal bacteraemia via the placental site [4, 5], however, endogenous metastatic infection during pregnancy is extremely rare. To the best of our knowledge, we present the first reported case of EBE in pregnancy, during the peripartum period. Postpartum cases of infective endophthalmitis have been reported due to fungal infections [2, 3]. Surprisingly, bacterial infections have not been reported more frequently given that 14% of women after labour or rupture of membranes show evidence of postpartum bacteraemia [4].

The exact mechanism of EBE is uncertain. We postulate that in this case, ascending bacterial infection from the vagina may have caused premature rupture of membranes [5]. This facilitated access of the bacterium into the maternal venous blood circulation via the placental site. A mild bacteraemia may have occurred (as our patient had mild fever and neutrophilia) which finally resulted in endophthalmitis. Another route of access into the systemic circulation was via the perineal tear, but this is less likely because of the rapid onset of ocular symptoms.

Sphingomonas paucimobilis is an aerobic, Gram-negative bacillus with a widespread distribution in the environment. It is known to cause septicaemia in immunocompromised patients as well as other nosocomial infections. The outcome did not appear to be compromised despite the delay in treatment with antibacterial antibiotics. This may be due to the relatively low pathogenicity of the S. paucimobilis bacteria which lacks lipopolysaccharide A in the cell wall [6] and therefore does not attract a particularly strong host inflammatory reaction compared to other Gram-negative organisms. This is only the third case of endophthalmitis caused by this organism. The other two cases were reported after cataract extraction [7, 8] and followed a relatively prolonged course with a satisfactory outcome.

Although rare, this case highlights the need for urgent examination of patients with a painful eye or visual deterioration in the peripartum period to exclude sight-threatening infection such as EBE.