Abstract
Purpose
To report a rare case of aseptic abscess presenting as a subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis.
Observations
A 25-year-old, male, Japanese patient with ulcerative colitis presented with an unilateral subconjunctival abscess. Infective endocarditis with endophthalmitis was suspected of being the cause, and systemic antimicrobial therapy was begun. The patient became critically ill and experienced the complication of heart failure with mitral valve perforation but improved dramatically with high-dose corticosteroids and intravenous infliximab following mitral valvuloplasty. His HLA typing was positive for HLA-B51.
Conclusions and importance
Both infectious and non-infectious etiologies should be considered in a patient with a subconjunctival abscess with systemic inflammation. An aseptic abscess can present as a subconjunctival abscess, and HLA-B51 may play a role in the pathogenesis of this rare condition.
1
Introduction
Subconjunctival abscesses are usually caused by a bacterial infection associated with a previous trauma or surgery or may be secondary to a systemic infection. Non-infectious etiologies are rarely reported but can occur spontaneously. Described herein is a case of an aseptic systemic abscess presenting as a sterile subconjunctival abscess associated with ulcerative colitis (UC) which was successfully treated with high-dose glucocorticoids and tumor necrosis factor alpha inhibitor.
2
Case report
A 25-year-old, male, Japanese patient was admitted for acute panuveitis accompanied by decreased vision in the right eye, which he discovered on waking. Ten days before onset, he visited a general ophthalmologist for redness in his right eye, general malaise, and fever. The ophthalmologist diagnosed uveitis and prescribed a steroid eye drop. The patient had no history of eye disease, injury or surgery but had received the diagnosis of UC six years ago and experienced a flare three months prior to the current admission. He was treated with mesalazine and tapered doses of prednisolone.
His best-corrected visual acuity was 20/200 in his right eye and 20/16 in his left eye. The right eye had ciliary hyperemia, anterior chamber inflammatory cells 4+, anterior chamber flare 4+, vitreous opacification 3+ according to the Standardization of Uveitis Nomenclature (SUN) criteria, and a subconjunctival abscess in the inferonasal area ( Fig. 1 ). The subconjunctival abscess was attached to the sclera and had no mobility. His left eye was unremarkable. His body temperature was 38.2 °C, a pansystolic murmur was audible in the apex, and mild tenderness was noted in the left lower quadrant of the abdomen. A pustular rash was observed on the face and trunk ( Fig. 2 ). Laboratory data showed elevated white blood cells (11,700/μL, neutrophils 83%, lymphocytes 9%) and C reactive protein (13.9 mg/dL). Transthoracic echocardiography showed severe mitral valve regurgitation due to anterior leaflet perforation with an aneurysm. Contrast-enhanced computed tomography (CT) visualized multiple lung nodules and multiple liver, splenic, intramuscular, and subcutaneous abscesses ( Fig. 3 ). Neither CT nor magnetic resonance imaging revealed any intracranial or cervical lesions.
An infection due to a pathogenic organism was thought to have caused the initial abscess, with secondary infections leading to the infective endocarditis and endogenous endophthalmitis with the subconjunctival abscess. However, Gram stain of fine needle aspiration specimens of the subconjunctival ( Fig. 4 ), subcutaneous, and intramuscular abscesses was negative for bacteria and fungi. Furthermore, three sets of blood cultures were also negative for pathogenic organisms. Surgical intraocular fluid sampling was considered but was not performed because the sclera was thin and highly inflamed and the possibility of prolonged wound healing was a matter of concern.
