Endogenous endophthalmitis is a rare, severe infection secondary to bacteremia. It affects intraocular fluids and can lead to vision loss. The most common sources of bacteremia are endocarditis, abdominal abscesses, endoscopic procedures, among others. An 82-year-old man with a history of prostate cancer treated with radiotherapy 5 years earlier, with chronic diarrhea since then, was hospitalized with ocular hyperemia, eye pain, and sudden decreased visual acuity in the left eye. Initially treated as herpetic uveitis, he evolved within 24 hours of symptom onset with decreased level of consciousness and confusion. On physical examination, there were no signs of seizure or other focal deficits. After stroke was ruled out by CT, cerebrospinal fluid (CSF) analysis showed: opening pressure 21 cm H₂O, turbid aspect, 7,173 cells/mm³ (predominantly neutrophils), protein 498 mg/dL, glucose 43 mg/dL, lactate 6.64 mmol/L, and negative direct tests and cultures for bacteria, fungi, and mycobacteria; viral panel was also negative. Blood cultures were negative. Empiric treatment with ceftriaxone, vancomycin, ampicillin, acyclovir, and dexamethasone was started for meningitis of unclear etiology. The patient was re-evaluated by ophthalmology, which ruled out ocular herpes and diagnosed left endophthalmitis. Culture of aqueous humor was positive for Streptococcus gallolyticus (bovis). Intravitreal injections of vancomycin and dexamethasone were administered, without improvement in visual acuity. The patient underwent vitrectomy, with abundant intraoperative pus and retinal foci of bleeding. After culture results, ceftriaxone 2g every 12 hours was maintained for 28 days. Further investigation included transthoracic echocardiography, which showed no vegetations, and colonoscopy, which revealed a mid-rectal stricture, scars in the cecum and colon, and colonic polyps compatible with tubular adenoma with low-grade dysplasia. The patient had complete recovery of neurological status after treatment, but maintained permanent visual deficit in the left eye. This patient developed bacterial meningitis and endogenous endophthalmitis likely of hematogenous origin, given the absence of prior ocular trauma/procedures. Streptococcus bovis bacteremia is classically associated with colorectal neoplasms, which were not found in this case; however, the history of chronic diarrhea associated with scarring lesions of radiation proctitis with chronic inflammation may be associated with translocation.
Santo et al. (2026) studied this question.