An unusual case of orbital abscess due to Morganella morganii and Klebsiella pneumoniae, following acute on chronic dacryocystitis

Rashmi K Nayak; Barnini Banerjee; H Vijaya Pai

doi:10.4103/IJO.IJO_3008_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 507-509

An unusual case of orbital abscess due to Morganella morganii and Klebsiella pneumoniae, following acute on chronic dacryocystitis

Rashmi K Nayak¹, Barnini Banerjee², H Vijaya Pai¹
¹ Department of Ophthalmology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
² Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission	14-Nov-2022
Date of Acceptance	05-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
H Vijaya Pai
Department of Ophthalmology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_3008_22

Abstract

Orbital abscess secondary to dacryocystitis is rare.^[1] Morganella morganii is a gram-negative rod and a facultative anaerobic enteric bacterium causing opportunistic infection, often isolated as a cause of nosocomial infection, specifically in urinary tract or wound infections. Risk factors may be old age, presence of concomitant bacteremia, hospitalization, recent surgery, concurrent antibiotic use, and immunocompromised hosts.^[2] According to authors' knowledge, till date, only one case of orbital abscess due to M. morganii has been reported secondary to sinusitis. There are no reports of orbital abscess due to M. morganii following dacryocystitis till date.^[3] We report a rare case of orbital abscess secondary to dacrocystitis caused by M. morganii and Klebsiella pneumoniae in an immunocompetent patient.

Keywords: Dacryocystitis, immunocompetent, Klebsiella pneumoniae, Morganella morganii, orbital abscess

How to cite this article:
Nayak RK, Banerjee B, Pai H V. An unusual case of orbital abscess due to Morganella morganii and Klebsiella pneumoniae, following acute on chronic dacryocystitis. Indian J Ophthalmol Case Rep 2023;3:507-9

How to cite this URL:
Nayak RK, Banerjee B, Pai H V. An unusual case of orbital abscess due to Morganella morganii and Klebsiella pneumoniae, following acute on chronic dacryocystitis. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 10];3:507-9. Available from: https://www.ijoreports.in/text.asp?2023/3/2/507/375011

Orbital abscess is a rare complication of chronic dacryocystitis due to the anatomy of orbital septum. Till date, only 10 cases of orbital abscess secondary to acute dacryocystitis have been reported.^{[1],[4],[5],[6],[7]} Staphylococcus and Streptococcus species, followed by Hemophilus influenzae and Pseudomonas aeruginosa are the common organisms implicated.^[8],[9] This case report emphasizes on culture report–based management of orbital abscess secondary to dacryocystitis caused by Morganella morganii and Klebsiella pneumoniae.

Case Report

A 52-year-old female with no systemic comorbidities presented with complaints of swelling, pain, redness, and diminution of vision in left eye (OS) of 2 days duration. She was using 625 mg oral amoxicillin and clavulanate 12 hourly for the past 2 days. She gave history of watering from OS for the past 2 years. She had undergone right external dacryorhinocystostomy 15 years ago. There was no history of diabetes. On examination, the patient was conscious, alert, and afebrile. Her visual acuity was 20/80 in the right eye (OD) and counting finger at 1 m in OS. Examination of OD was normal, and OS showed lid edema, dystopia of 3 mm (eye was displaced downward and outward) with limitation of all the extraocular movements, and marked chemosis of the conjunctiva [Figure 1]a. Left pupil was 4 mm and showed relative afferent pupillary defect. Fundus examination was normal in both eyes. A provisional diagnosis of orbital cellulitis secondary to acute on chronic dacryocystitis was made and blood culture was sent. Hemogram showed leukocytosis (19.6 × 10⁹/l), with neutrophilia (86.6% segmented neutrophils). Random blood sugar was149 mg/dl and glyco-HbA1c was 5.5%. She was started on intravenous 1.2 g amoxicillin with clavulanic acid twice daily and 500 mg metronidazole thrice daily. Computerized tomogram (CT) of orbit done before initiation of treatment showed left-side proptosis, soft tissue swelling, with fat stranding in preseptal, postseptal, extraconal, intraconal, premaxillary-zygomatic and prefrontal regions, suggestive of cellulitis. Soft tissue thickening with hypodense fluid collection was noted in the medial aspect of the left orbit, medial to the medial rectus [Figure 2]a. Hypodense fluid collection in the medial part of the orbit extending from lacrimal sac, lacrimal sac appeared bulky, fluid filled [Figure 2]b. A diagnosis of orbital cellulitis with orbital abscess, secondary to acute on chronic dacryocystitis in the OS was made. Transnasal endoscopic medial orbital decompression was performed under general anesthesia by the otorhinologist. The pus was sent for bacterial culture. Post-op, there was no improvement; proptosis and lid edema increased. Ultrasonography scan of the left orbit showed collections with internal echoes in the left preseptal region, extending along the medial wall of the left orbit, measuring 3.7 × 2.7 cm; the left lacrimal sac appeared bulky and fluid filled. Blood culture showed no growth after 48 h. Transcutaneous drainage of the abscess through skin incision in the medial part of the lower lid and upper lid was done under general anesthesia. Pus culture showed heavy growth of M. morganii and K. pneumoniae [Figure 1]b sensitive to amikacin, gentamicin, ceftriaxone, sulfamethoxazole, and trimethoprim and resistant to amoxicillin–clavulanic acid, ampicillin, and ciprofloxacin. Patient was started on oral sulfamethoxazole 800 mg and trimethoprim 160 mg twice a day. On the fourth postoperative day, vision in the OS improved to counting finger at 3 m and there was marked decrease in the eyelid edema; the ocular motility improved and 3 mm reduction in proptosis was noted. At 1 week of follow-up, visual acuity was 20/200 in OS, and syringing of left lacrimal sac showed regurgitation of mucopurulent discharge from the opposite punctum with hard stop. Four weeks later, the patient underwent external dacryocystorhinostomy (DCR) on the left side [Figure 1]c. Two months post-DCR, the patient was doing fine.

Figure 1: (a) Photograph showing OS proptosis (eye was pushed downward and outward) and marked conjunctival chemosis (white arrow). (b) Photograph showing growth of Morganella morganii (white arrow) and Klebsiella pneumoniae (blue arrow). (c) Photograph post-DCR (white arrow). DCR = dacryocystorhinostomy, OS = left eye

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Figure 2: CT images of the orbit. (a) Axial section and (b) coronal section showing left proptosis and soft tissue swelling with fat stranding in preseptal, postseptal, extraconal, and intraconal regions of the left orbit and in left premaxillary-zygomatic and prefrontal regions, suggestive of cellulitis. Soft tissue thickening with hypodense fluid collection noted in the medial aspect of left orbit, medial to the medial rectus. Conical pull or tenting of posterior globe due to stretching and displacement of eyeball downward and outward (white arrow). Hypodense fluid collection in the medial part of the orbit extending from the lacrimal sac noted. Lacrimal sac bulky and fluid filled (blue arrow). CT = computed tomography

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Discussion

Complications associated with untreated chronic dacryocystitis are acute dacryocystitis, lacrimal sac abscess leading to fistula or preseptal cellulitis, and rarely, orbital cellulitis and orbital abscess.^[4] Lacrimal sac abscess causes preseptal cellulitis rather than orbital cellulitis or abscess as insertion of medial palpebral ligament prevents extension into the orbit. Orbital abscess usually occurs in an immunocompromised state in patients with diabetes or recurrent episodes of acute dacryocystitis in a setting of chronic dacryocystitis.

Our patient did not have any previous episodes of acute dacryocystitis or systemic comorbidities like diabetes. This brings to us the possibility of highly virulent atypical organisms involved in the pathogenesis of orbital abscess and the importance of microbiological investigation in such cases.

The most common organisms implicated in chronic dacryocystitis are gram-positive organisms like Staphylococcus and Streptococcus, gram-negative organisms like H. influenzae and K. pneumoniae, Pseudomonas aeruginosa, Citrobacter, and Enterobacter. In our patient, culture of pus and endonasal specimen grew M. morganii and K. pneumoniae,^[8],[9] confirming the causative nature of the organism.

M. morganii usually causes opportunistic infection, nosocomial or urinary tract infection in patients on immunosuppressive therapy, diabetics, or acquired immunodeficiency syndrome (AIDS) patients.^[2] Singh et al.^[3] reported a case M. morganii orbital abscess secondary to sinusitis, whereas in our patient, it was chronic dacryocystitis causing orbital abscess. There was no evidence of sinus involvement on imaging. K. pneumoniae rarely causes orbital abscess with vascular occlusion and is reported in cases of diabetes, deep neck infections, or liver abscess causing endophthalmitis.^[10]

Initial therapy with intravenous amoxicillin–clavulanate and metronidazole did not show any good response. The pus grew M. morganii and K. pneumoniae that were sensitive to amikacin, gentamicin, ceftriaxone, sulfamethoxazole, and trimethoprim and resistant to amoxicillin–clavulanic acid, ampicillin, and ciprofloxacin. On switching to sulfamethoxazole and trimethoprim combination, there was marked resolution of the signs.

Conclusion

In our patient, early surgical intervention and appropriate antibiotic change guided by culture and sensitivity report helped in achieving good outcome. When there is no response to the regular antibiotics, one must consider the possibility of atypical organism as the cause of infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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