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Endophtalmie endogène à staphylococcus warneri chez une femme atteinte de polyarthrite rhumatoïde

Endogenous endophtalmitis (EE) is a severe metastatic infection of the orbit happening in patients with special health conditions. Herein we report a case of Endogenous endophthalmitis due to staphylococcus warneri in a Tunisian woman with rheumatoid arthritis.

A case of endogenous endophthalmitis due to staphylococcus warneri in a Tunisian woman with rheumatoid arthritis.

A 56 year old woman with rheumatoid arthritis treated by methotrexate presented for a red painful right eye with blurred vision which has lasted 3 days. Visual acuity in her right eye was limited to light perception and counting fingers at 2 m in the left. The slit lamp examination of the right eye revealed conjunctival hyperemia, 4+ cells in the anterior chamber, 2 mm hypopyon, normal intraocular pressure, mild vitritis with a fundus that was blurred but seemed normal. A presumptive diagnosis of endogenous endophtalmitis from a cerebral start point infection was established based on an orbital MRI scan that showed multiple nodular lesions and plaques. The fundus examination showed an appearance of creamy white flake lesion in the vitreous 48 hours after systemic corticosteroids. A deepest history taking noticed that the patient has been hospitalized in the cardiology department due to viral myocarditis. A cardiac ultrasound showed a non-compressive pericardial effusion without signs of vegetation or a valve leak. A diagnostic vitrectomy found a peripheral temporal flake of 1 disc diameter in size which was surrounded by others smaller flakes. The vitreal culture was positive to staphylococcus warneri and an adapted systemic antibiotherapy was started.  MRI assessment revealed the disappearance of initial brain lesions.  The patient unfortunately did not regain vision despite treatment. visual acuity in the right eye 5 months after this episode was counting fingers at 2 meters.

Bacterial endogenous endophtalmitis happens mostly in predisposed fields associated with risk factors. Within the family of Gram-Positive bacteria, staphylococcus aureus and streptococcus pneumoniae are mainly found all regions combined. Endocarditis du to staphylococcus warneri should be considered in patients with new cardiac heart failure even if typical signs of infection such as fever and leukocytosis are absent. The treatment is usually based on intravitreal injection of ceftazidime and vancomycin.

This case illustrates the possibility of severe EE due to staphylococcus warneri. It demonstrates again the importance of vitrectomy as a diagnostic key and a therapeutic weapon in difficult situations. Nevertheless EE stays a severe ocular infection that threats the visual outcome of the patient although an early and adapted therapy is established.