Virginia Research Day 2025

Medical Student Research Case Reports

32 Endophthalmitis in the Setting of MRSA Bacteremia: A Case Report

Sally S. Greenberg, MS3; Kainuo Wu, MD; Lauren Mazin, DO; Bupesh Dogra, MD Corresponding author: sgreenberg@vcom.edu

Edward Via College of Osteopathic Medicine - Virginia Campus Salem VA Medical Center

emergency department with a 1-week history of flu like symptoms in the setting of Sars-CoV-2 (COVID) and 7/10 left foot pain. He was hemodynamically stable and afebrile. Physical exam was notable for tophaceous features in the left metatarsophalangeal joint of the first digit with surrounding erythema and chalky white excretions. Initial labs revealed normal uric acid (6 mg/dL), elevated erythrocyte sedimentation rate (79 mm/hr), and elevated C-reactive protein (34.8 mg/L). Patient was admitted with an acute gout flare and a COVID infection. He received intravenous (IV) fluids, prednisone, and his pain control was optimized. Several hours after admission, he developed worsening foot pain and purulent drainage. Further workup revealed elevated procalcitonin (35.57 ng/mL). Empiric vancomycin was initiated and he was taken to the operating room for his first wound debridement. Blood cultures grew MRSA. Blood cultures remained persistently MRSA positive despite 48-72 hours of vancomycin therapy. Echocardiogram was negative for vegetations. Infectious disease was consulted and IV ceftaroline

was added for dual coverage. On hospital day 4, patient developed acute monocular vision loss of the left eye. Ocular exam noted haziness with cotton-like spots on the retina accompanied by yellow discharges and diffuse subconjunctival hemorrhages consistent with EnE. He received an intravitreal injection of vancomycin, ceftazidime, voriconazole, and foscarnet followed by daily prednisolone and atropine eye drops. After the final debridement of his foot, imaging confirmed osteomyelitis in multiple left metatarsals. Due to the persistent nature of the infection, he underwent a below-the-knee amputation of the left limb. Blood cultures were repeated and were negative. Thus, ceftaroline was discontinued as persistent bacteremia was suspected to be due to incomplete source control prior to amputation. Ocular symptoms continued to improve and he was discharged to long term rehabilitation with four weeks of IV vancomycin and a prednisolone eye drop taper. The authors received patient consent to use their data for this case report.

Introduction: Methicillin resistant staphylococcus aureus (MRSA) bacteremia is a bloodstream infection associated with complications and poor clinical outcomes. 0.2% of individuals with MRSA bacteremia develop endophthalmitis, a complication characterized by inflammation of intraocular fluids secondary to bacterial or fungal infections, and is considered an ophthalmologic emergency due to the risk of blindness. The etiology of endophthalmitis may be further classified as exogenous, from external inoculation, or endogenous, from hematogenous seeding that crosses the blood ocular barrier. Endogenous endophthalmitis (EnE) is very rare, accounting for approximately 5-10% of cases, with little description in the literature resulting in a lack of current standardized treatment guidelines. This case presents a patient with EnE secondary to MRSA bacteremia, specifically highlighting the diagnostic and treatment approach. Case Presentation: A 63-year-old male with a history of gout and recurrent MRSA bacteremia secondary to phalangeal infections, presented to the

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