Abstract
Purpose
To describe multiple ocular (and non-ocular) manifestations of disease that can present in a person who injects drugs (PWID). We report a case of a patient consecutively presenting across multiple visits to an ambulatory eye care clinic as the initial point of contact for endogenous endophthalmitis, fungal keratitis, bacteremia, and psoas abscess with vertebral osteomyelitis within a matter of weeks.
Observations
A 51-year-old male with past medical history of alcohol use disorder and injection drug use was initially seen in an eye clinic three days after suffering vision loss in the left eye associated with floaters, photophobia, and eye pain. After initial workup and treatment for panuveitis, endogenous endophthalmitis was suspected. A pars plana vitrectomy was performed, and intravitreal medications were given. A pathogen was never isolated from vitreous samples. Two weeks later, the patient presented with complaints of pain, blurry vision, and foreign body sensation in his opposite (right) eye. Examination revealed a corneal ulcer later identified as a Paecliomyces fungal infection. Two weeks after this, he developed fever, chills, and right-sided flank pain radiating to his testicles. Following evaluation by the emergency department and subsequent hospitalization after bacteremia was noted, he was found to have a right-sided psoas abscess with lumbar vertebral osteomyelitis. Fluid was drained, cultured, and grew methicillin-sensitive Staphylococcus aureus (MSSA). At his last visit, his best-corrected visual acuity was 20/20 OS and 20/30 OD despite central corneal scarring. It was only after hospitalization that he affirmed recent injection drug use, despite being queried about it through the course of his infections.
Conclusions and importance
Injection drug use is an increasingly common concern for all healthcare providers as the opioid crisis in the United States remains widespread. This case highlights multiple potential infectious processes which may impact persons who inject drugs when seen by eye care providers. It also describes difficulties in caring for people who inject drugs who may not provide critical and timely information relating to their injection drug use and/or may delay care even when faced with potentially vision- and/or life-threatening conditions.
1
Introduction
The ongoing opioid crisis in the United States has created new hurdles for health care practitioners across every discipline. According to CDC data, between 1999 and 2018, nearly 450,000 deaths were attributed to opioid overdose. In 2018, out of the 67,367 deaths due to drug overdose, 70% (46,802) involved opiates – an average of nearly 130 deaths per day. In 2017, over 11 million Americans (aged 12 and older) were opiate misusers, with approximately 886,000 reporting heroin use within the previous year. The economic burden placed on the U.S. through prescription opiate abuse-related medical costs, lost productivity, criminal justice efforts, and substance abuse treatment are estimated between 70 and 90 billion dollars annually. Injection drug use (IDU) places patients at high risk of bacterial infection which can lead to skin abscess, sepsis, pneumonia, and infective endocarditis. Acute Hepatitis C cases also more than doubled in the U.S. between 2004 and 2014, in direct correlation with the widespread increase of intravenous opiate use.
From an ophthalmic perspective, a major consequence of IDU is endogenous endophthalmitis (EE), and particularly endogenous fungal endophthalmitis (EFE). Multiple case series have reported IDU as a risk factor associated with EFE ranging from 23.1% in a 10-year study of 64 cases at a tertiary referral center in Australia, to as high as 70% in another study of 27 patients conducted between 2001 and 2007. Both bacterial and fungal causative agents have been identified in EE, but multiple studies have shown that fungal organisms (most commonly Candida sp.) account for the majority of cases. , Through hematogenous spread, microbes can travel to the eye and cause an infectious posterior uveitis. This can present as vitritis, chorioretinal lesions, or can develop into the classic “string-of-pearls” sign due to fungal colonization of the vitreous.
An additional sight-threatening complication of IDU and other forms of substance abuse is bacterial or fungal infection of the cornea. Timely access to care may be a complicating factor to consider in persons who inject drugs (PWID). Many have experienced and/or perceive discrimination and mistreatment when interacting with healthcare professionals and may subsequently avoid the potential stigmatization associated with accessing health care services. Any delay in care can be consequential since both endophthalmitis and corneal ulcers need to be treated in a timely manner for best visual prognosis. ,
2
Case report
We present a 51-year-old male with previous history of alcohol use disorder and IDU who reported a three-day history of left eye vision loss associated with new floaters, photophobia, and eye pain. The patient noted that a corneal metallic foreign body was removed from his left eye three months prior. He also reported a recent history of fever, lip blisters, and cellulitis for which he received a 10-day course of cephalexin. He had prior history of LASIK surgery in both eyes and was an active soft contact lens wearer. There was no history of recent hospitalization, intraocular procedures, diabetes mellitus, surgery, catheterization, or recent dental work. The patient did report history of IDU within six months prior to his presentation, but he denied current injection drug use.
At initial presentation, best corrected visual acuity (BCVA) in his right eye was 20/20 and left eye was 20/70. Slit lamp examination of the right eye showed 1+ conjunctival injection with an otherwise normal exam. Exam of the left eye revealed 3+ conjunctival injection, an old corneal stromal scar without epithelial defect, pigmented endothelial keratic precipitates, and an anterior chamber reaction of 3+ cells, 2+ flare, and posterior synechiae. Fundus exam of the right eye was normal. The left eye revealed a hazy view secondary to 2+ vitritis with inflammatory snowballs and a yellow chorioretinal lesion superotemporal to the fovea ( Fig. 1 ). Labs including ESR, HIV, syphilis IgG/IgM, ACE, Lyme, toxoplasmosis IgG/IgM, QuantiFERON-TB Gold, HLA-B27, and RF were sent as part of a uveitis work-up. Due to the yellow chorioretinal lesion and clinical suspicion for toxoplasmosis-related posterior uveitis, he was also started on SMX-TMP 800 mg/160 mg PO twice daily, prednisolone acetate 1% every 2 h, and atropine 1% twice daily.
The next day, his ESR, HIV, RF, and syphilis IgG/IgM results returned negative. He was asked to return to the clinic over the following week, but did not demonstrate an expected response to antibiotic therapy. Due to concern for endogenous endophthalmitis, blood cultures were drawn and the patient underwent pars plana vitrectomy with vitreous biopsy and intravitreal injection of 100 mcg voriconazole, 1 mg vancomycin, 2.25 mg ceftazidime, and 400 mcg dexamethasone. Vitreous samples were sent for quantitative PCR for toxoplasmosis, HSV 1 and 2, VZV, and CMV. Vitreous cultures were placed in thioglycolate and brain heart infusion (BHI) broths as well as plated on blood agar, chocolate agar, Columbia nalidixic acid (CNA) agar, Sabouraud dextrose agar (SDA), and inhibitory mold agar (IMA). Blood cultures were plated on blood agar and chocolate agar.
During the following two weeks of post-op visits, ACE, Lyme, HLA-B27, QuantiFERON-TB Gold, fungal and bacterial vitreous cultures with Gram/fungal stain, qPCR for toxoplasmosis, HSV 1 and 2, VZV, CMV, and blood cultures all returned negative. The patient improved clinically with resolution of the intraocular inflammation and left eye visual acuity recovered to 20/30. Due to the clinical improvement associated with vitrectomy and intraocular antibiotics, endogenous endophthalmitis was suspected despite negative culture results.
Two weeks later, the patient returned reporting symptoms of pain in his opposite (right) eye, blurry vision, and a foreign body sensation. Best-corrected distance vision in his right eye was count fingers at 1’ and his left eye was 20/40. Slit lamp examination revealed a central, oval corneal ulcer measuring 3 mm vertically by 2 mm horizontally with infiltrate, and an anterior chamber reaction of 3+ cells without hypopyon ( Fig. 2 ). Slit lamp exam of the left eye was normal. Dilated fundus examination of both eyes was normal. Corneal culture was taken from the right eye and he was started on polymyxin B sulfate 10,000 units/mL with trimethoprim sulfate equivalent to 1 mg/mL (Polytrim) ophthalmic suspension four times daily and valaciclovir 1000 mg PO three times daily.
