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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 162-164

Bilateral Mycobacterium abscessus chronic endophthalmitis presenting as retinitis in a human immunodeficiency virus positive young male – A case report


1 Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bangalore, Karnataka, India
2 Department of Vitreoretinal Services, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bangalore, Karnataka, India

Date of Submission06-Jul-2021
Date of Acceptance31-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Kalpana Babu
Prabha Eye Clinic and Research Centre, 504, 40th Cross, Jayanagar 8th Block, Bangalore - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1826_21

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  Abstract 


We report an interesting case of chronic endophthalmitis presenting as bilateral retinitis with chronic granulomatous inflammation due to Mycobacterium abscessus in a 17-year-old human immunodeficiency virus (HIV)-positive young male. The diagnosis was made on the basis of cytopathology, culture, and genomic sequencing on the vitreous biopsy. The treatment included antitubercular therapy, intravenous meropenem, and intravitreal amikacin injections. At the end of 6 months, the retinitis resolved well and best-corrected visual acuity (BCVA) was 6/9 both eyes (OU). Though endophthalmitis due to M. abscessus has been described in the literature, bilateral retinitis is rare and is being described in this case report.

Keywords: Bilateral retinitis, chronic endophthalmitis, HIV, Mycobacterium abscessus


How to cite this article:
Mukesh K, Shah D, Murthy KR, Babu K. Bilateral Mycobacterium abscessus chronic endophthalmitis presenting as retinitis in a human immunodeficiency virus positive young male – A case report. Indian J Ophthalmol Case Rep 2022;2:162-4

How to cite this URL:
Mukesh K, Shah D, Murthy KR, Babu K. Bilateral Mycobacterium abscessus chronic endophthalmitis presenting as retinitis in a human immunodeficiency virus positive young male – A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 28];2:162-4. Available from: https://www.ijoreports.in/text.asp?2022/2/1/162/334913



We report a rare case of chronic endophthalmitis presenting as bilateral retinitis with chronic granulomatous panuveitis due to Mycobacterium abscessus (M. abscessus) in a 17-year-old retrovirus positive male.


  Case Report Top


A 17-year-old HIV+ male was referred from the neurology department for an ocular evaluation. He had a progressive diminution of vision in both eyes of 6 months duration. He was on antiretroviral therapy (tenofovir, lamivudine, dolutegravir) for 1 year and antitubercular therapy (isoniazid, rifampicin, pyrazinamide) for 2.5 years for a diagnosis of chronic meningitis due to presumed tuberculosis. He also had a neurogenic bladder. At the time of examination, his CD4 counts were 280 cells/mm3. The cerebrospinal fluid analysis (microscopy, culture, and polymerase chain reaction) for Mycobacterium tuberculosis (MTb), venereal disease research laboratory test (VDRL), and toxoplasmosis were negative. There was doubtful positivity for Cryptococcus on India ink preparation. The blood and urine cultures were negative. Enzyme-linked immunosorbent assay (ELISA) for toxoplasmosis, VDRL, and treponemal pallidum hemagglutination tests, Mantoux and QuantiFERON TB gold tests were negative. Hepatitis C and Hepatitis B surface antigen tests were negative. The chest X-ray was normal. The magnetic resonance imaging (MRI) of the orbits and cranium did not reveal any significant abnormality.

On ocular examination, his BCVA was 6/18 right eye (OD) and 6/9 left eye (OS). The slit-lamp examination (OU) showed medium-sized keratic precipitates, anterior chamber reaction 2+ (Standardization of Uveitis Nomenclature),[1] and posterior subcapsular cataractous changes [Figure 1]. The fundus examination both eyes revealed vitritis with multiple confluent, and creamy lesions in the periphery suggestive of bilateral retinitis [Figure 2]. The intraocular pressures were in the normal range. The AC tap was negative for eubacterial, pan fungal, and Mycobacterium tuberculosis (MTb) genomes on polymerase chain reaction (PCR). Due to the doubtful cryptococcal positivity in the cerebrospinal fluid (CSF), he had received intravenous amphotericin B (0.5 mg/kg/day × 12 days) and was referred to the ophthalmology department with oral fluconazole 225 mg/day and Sulfamethoxazole 800mg + Trimethoprim 160mg bd. The retinitis and vitritis had marginally increased in the left eye. He was administered a single intravitreal injection of amphotericin B (5 mcg/0.1 mL). The following day, he developed hypopyon in the left eye with increasing vitritis and the vision had dropped to counting fingers close to the face [Figure 3].
Figure 1: Slit-lamp photograph showing medium-sized keratic precipitates (a) with posterior subcapsular cataract (b)

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Figure 2: Fundus photographs of the right eye (a), left eye (b), and OCT image of the right eye (c) and left eye (d) showing vitritis and retinitis

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Figure 3: Slit-lamp photograph showing hypopyon in the left eye (a) and fundus photograph of the left eye (b) showing an increase in vitritis and retinitis after administering intravitreal amphotericin B injection

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He underwent a vitrectomy and the vitreous was sent for cytology and microbiology (Gram stain, potassium hydroxide, acid-fast stain; culture for bacteria, fungi, and mycobacteria and PCR for eubacterial, pan fungal, MTb, herpes simplex virus, varicella zoster virus, and cytomegalovirus genomes). He was given intravitreal broad-spectrum antibiotics (amikacin, vancomycin, and voriconazole) while awaiting the results. His vision had improved to 6/18(OS) on the first postoperative day and resolving inflammation.

The cytology showed chronic granulomatous inflammation with a few intracellular acid-fast bacilli suggestive of tubercular pathology. However, the PCR for MTb genomes was negative. The BACTEC™ revealed some growth in 6 days suggestive of rapid growers of atypical mycobacteria. The genomic sequencing revealed M. abscessus sensitive to imipenem, clarithromycin, amikacin, and gatifloxacin. Along with antitubercular therapy, he was started on intravenous meropenem (1 gm thrice a day for 6 weeks), oral azithromycin (500 mg/day), and continuation of antitubercular therapy. In addition, he also received multiple injections of amikacin (125 μg/0.1 mL) to both eyes. There was a gradual resolution of retinitis in both eyes. At 6 months follow-up, his BCVA was 6/9 (OU). The vitritis and retinits had resolved completely with pigmentary changes [Figure 4].
Figure 4: Fundus photograph of the right eye (a), left eye (b), and OCT image of the left eye (c) at 6 months follow-up showing completely resolved vitritis and retinitis with pigmentary changes

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  Discussion Top


M. abscessus is a member of the Mycobacterium fortuitum complex family of rapidly growing mycobacteria (Runyon classification Group IV) belonging to the atypical mycobacteria. The risk factors include trauma, corneal infections or surgery, corticosteroid use, and systemic immunosuppression.[2],[3] Endophthalmitis caused by M. abscessus, though rare, has been described and is generally associated with poor visual outcomes and generally results in evisceration, enucleation, or phthisis bulbi.[4] Bilateral retinitis due to M. abscessus has not been described in the literature (MEDLINE search). The poor prognosis of these infections is due to the delay in the diagnosis and the differential response to antibiotics. Amikacin is thought to be the first-line antibiotic of choice for ocular infections. It requires minimum inhibitory concentration analysis of the antibiotic to be used. Standard anti-tuberculosis drugs such as isoniazid and rifampicin are commonly prescribed. Amikacin, clarithromycin, and/or azithromycin are considered to be the best antibiotics for nontuberculous Mycobacterium infections. Intravenous amikacin and imipenem have also been reported to be successful in the management of these cases. Prolonged systemic therapy and multiple intravitreal injections may be the key to successful management.[5]

A high index of suspicion of atypical mycobacterial infections is necessary especially in immunocompromised patients with chronic granulomatous intraocular inflammation.

The highlights in our case include, first, the presence of chronic granulomatous inflammation in the form of medium-sized keratic precipitates with bilateral slowly progressing creamish-yellow areas of retinitis in the periphery in an HIV+ patient with good CD4 counts. This characteristic clinical pattern should alert the clinician for a possible atypical mycobacterial infection. Second, the role of cytopathology is very crucial as shown by the identification of the intracellular bacteria on the vitreous cytology. The PCR for mycobacteria was negative on multiple occasions and in different centers. If we rely only on PCR, there is a possibility that this infection can be missed.[5] So cytology plays an important role in the identification of these organisms. Culture-yielded growth was identified on gene sequencing as M. abscessus. Though our patient was on antitubercular therapy, treatment of M. abscessus requires the addition of other antibiotics like amikacin, clarithromycin, imipenem, and azithromycin. Third, the early diagnosis and prompt systemic and intravitreal treatment resulted in a good visual prognosis in our case.


  Conclusion Top


Bilateral retinitis with chronic granulomatous inflammation due to M. abscessus has been first described in this case report. This clinical pattern should alert a high index of suspicion in an HIV+ individual of an atypical mycobacterial infection. If diagnosed and treated early, they can be associated with a good visual prognosis.

Acknowledgments

The authors acknowledge Dr. Krishnakumar S and Dr. Janani Sridhar, Vision Research Foundation, Sankara Nethralaya, Chennai for their help in cytopathology and gene sequencing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-16.  Back to cited text no. 1
    
2.
Moorthy RS, Valluri S, Rao NA. Nontuberculous mycobacterial ocular and adnexal infections. Surv Ophthalmol 2012;57:202-35.  Back to cited text no. 2
    
3.
Kheir WJ, Sheheitli H, Abdul Fattah M, Hamam RN. Nontuberculous mycobacterial ocular infections: A systematic review of the literature. Biomed Res Int 2015;2015:164989.  Back to cited text no. 3
    
4.
Shah M, Relhan N, Kuriyan AE, Davis JL, Albini TA, Pathengay A, et al. Endophthalmitis caused by nontuberculous mycobacterium: Clinical features, antimicrobial susceptibilities, and treatment outcomes. Am J Ophthalmol 2016;168:150-6.  Back to cited text no. 4
    
5.
Brown-Elliott BA, Woods GL. Antimycobacterial susceptibility testing of nontuberculous mycobacteria. J Clin Microbiol 2019;57:e00834-19.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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