A Rare Case of Streptococcus dysgalactiae Panophthalmitis and Concurrent Septic Arthritis from Hematogenous Spread: A Case Report

Authors: Lucas Goetz, Michael Eide

Abstract

Introduction

Panophthalmitis is a severe ocular infection with significant morbidity, most commonly caused by Staphylococcus aureus or Streptococcus pneumoniae. Streptococcus dysgalactiae is a rare cause of panophthalmitis, and its involvement in concurrent systemic infections is exceedingly uncommon.

Case Presentation

We report a case of S. dysgalactiae panophthalmitis in an elderly male patient, associated with bacteremia and septic arthritis. Despite early antimicrobial therapy, the infection progressed rapidly, ultimately requiring evisceration of the affected eye.

Conclusion

This case underscores the importance of early recognition, aggressive treatment, and systemic evaluation in patients with rapidly progressive ocular infections caused by atypical organisms.

Introduction

Panophthalmitis is a severe, sight-threatening condition characterized by inflammation of all ocular structures, often resulting in irreversible vision loss. It is a more advanced form of ocular infection than endophthalmitis, which is primarily limited to the internal structures of the eye. Both conditions can arise from trauma, surgery, or endogenous spread. Common pathogens associated with panophthalmitis include Staphylococcus aureus, Streptococcus pneumoniae, and Klebsiella pneumoniae [1], with hematogenous spread being a rare but recognized mechanism of infection. Hematogenous spread often occurs in immunocompromised individuals or those with underlying systemic infections, in which bacteria disseminate via the bloodstream to the ocular structures.

S. dysgalactiae is a β-hemolytic, Gram-positive cocci [2] typically found in the upper respiratory tract and as a commensal organism in humans. While it has been associated with soft tissue infections and bacteremia, its role in ocular infections, particularly panophthalmitis, is unusual. Recently, however, an increasing number of reports have highlighted its role in endogenous endophthalmitis, likely due to improved detection and rising infection rates. With similar genetic characteristics to Streptococcus pyogenes [3], this organism possesses significant virulence factors that make it capable of causing aggressive infections, including septic arthritis and panophthalmitis. Despite the rising incidence, severe ocular infection caused by S. dysgalactiae remains rare. A review of 342 cases of endogenous bacterial endophthalmitis found only 4 cases associated with this pathogen, with K. pneumoniae and S. aureus being far more common [1].

Similarly, S. dysgalactiae is an uncommon cause of septic arthritis. A study by Dubost et al. [4] reviewing 303 cases of septic arthritis in adults found only 2 cases linked to S. dysgalactiae.

The identification of this pathogen in both panophthalmitis and septic arthritis in the current case is exceptionally rare and underscores the importance of recognizing potential hematogenous spread, especially when unusual pathogens are involved [5]. The rapid progression of symptoms in this patient highlights the value of early recognition, timely diagnostic workup, and aggressive treatment to prevent severe complications, including vision loss and the need for surgical intervention.

Case Presentation

A 77-year-old male with a history of hypertension, atrial fibrillation, gout, liver cirrhosis, and B-cell lymphoma presented to the emergency department on day 1 with 3 days of rapid-onset right eye redness, discharge, and blurry vision. He denied trauma, fever, or chills. His most recent eye exam within the past year had been normal. He had also recently undergone extraction of an infected lower left wisdom tooth.

At the emergency visit, the patient was prescribed polymyxin eye drops six times daily and referred to ophthalmology. On day 3, he was evaluated in the ophthalmology clinic for worsening symptoms. He reported new right upper eyelid ptosis and decreased vision in the right eye. He also noted new right wrist swelling and right leg stiffness. Visual acuity was light perception in the right eye, and 20/20 in the left eye. Examination showed significant ptosis (MRD 0 mm OD), 4+ conjunctival injection, mild chemosis, and white discharge, which was sent for culture. The pupil was mid-dilated and poorly reactive. Corneal findings included diffuse haze, endothelial changes, and a linear superior epithelial defect, with no hypopyon or fibrin. Although a linear epithelial defect was initially noted at the slit lamp, subsequent fluorescein staining revealed a more extensive epithelial loss, consistent with a near-total defect. The posterior segment could not be visualized. Figure 1 depicts the affected right eye with injected and inflamed conjunctiva, a mostly opaque cornea, and yellow fluorescein staining consistent with a total epithelial defect.

Due to concern for possible third nerve palsy and cavernous sinus involvement, urgent imaging was obtained. However, neuroimaging revealed no abnormalities of the cavernous sinus or cranial nerves. The ptosis and mid-dilated, poorly reactive pupil were ultimately attributed to severe anterior segment inflammation and possible mechanical effects from globe distortion and a dislocated lens, rather than true neurogenic palsy. A CT/CTA and MR/MRA of the head, as well as CT of the orbits and sinuses, were performed. MRI, ordered early in the evaluation, demonstrated a dislocated intraocular lens (IOL) dependently positioned in the vitreous (Fig. 2), uveal thickening, and optic nerve buckling with surrounding fluid.

The dislocated IOL was not initially appreciated on slit lamp examination but was first identified on MRI. These findings supported posterior involvement, but the diagnosis of endophthalmitis was made clinically, and the decision to perform intravitreal tap and inject was not delayed by imaging.

At that visit, the patient was switched to neomycin-polymyxin-dexamethasone eye drops four times daily to address the significant anterior segment inflammation. Although topical corticosteroids are typically avoided in the setting of suspected infection, the initial differential prioritized non-infectious inflammation, and dexamethasone was initiated empirically while diagnostic testing was pending. This decision was reevaluated, and the drops were discontinued later the same day as concern for endophthalmitis increased.

Later on day 3, the patient was admitted to the hospital. Intravenous ceftriaxone was initiated. Infectious disease and orthopedic surgery were consulted, and joint aspiration and blood cultures were obtained. The ophthalmology team reevaluated the patient and initiated topical fortified vancomycin and tobramycin eye drops, along with erythromycin ointment, for presumed microbial keratitis.

On day 5, considering worsening ocular findings and persistent concern for endophthalmitis, the patient underwent a vitreous tap followed by intravitreal injection of vancomycin and ceftazidime. Cultures from the vitreous fluid, synovial fluid, and blood all grew S. dysgalactiae, confirming hematogenous dissemination of infection. A repeat vitreous culture, incubated under anaerobic conditions, yielded light growth of S. dysgalactiae, further supporting intraocular involvement.

These findings confirmed the diagnosis of endogenous panophthalmitis secondary to S. dysgalactiae bacteremia with concurrent septic arthritis. Despite aggressive systemic and intravitreal antibiotic therapy, the patient’s right eye vision deteriorated to no light perception.

During hospitalization, the patient was treated with intravenous ceftriaxone and topical antibiotics, with multidisciplinary input from ophthalmology, infectious disease, and orthopedic surgery. Joint symptoms improved with antimicrobial therapy, and follow-up cultures confirmed clearance of bacteremia. Given the poor prognosis for visual recovery and ongoing eye pain, the patient ultimately underwent right eye evisceration with orbital implant placement approximately 2 months after discharge. No postoperative complications were noted in the perioperative period, although long-term follow-up data are unavailable at this time.

Discussion

This case highlights a rare presentation of panophthalmitis caused by S. dysgalactiae, an organism more commonly associated with bacteremia and soft tissue infections than intraocular involvement. The most common pathogens in panophthalmitis include S. aureus and S. pneumoniae, with hematogenous spread to the eye being an infrequent yet well-documented mechanism of infection [1]. In the presented case, the simultaneous involvement of the eye and knee, along with positive S. dysgalactiae cultures from the vitreous, synovial fluid, and blood, strongly suggests systemic dissemination [5].

The rapid progression [6] to a frozen globe necessitated urgent intervention, including intravitreal injections and systemic antibiotics. Despite these measures, disease progression ultimately led to evisceration, emphasizing the need for timely recognition and aggressive treatment to prevent further complications.

The pathogenesis in this case may reflect either hematogenous dissemination or local extension from severe anterior segment infection. Although the patient initially presented with conjunctival injection and a corneal epithelial defect – features that could suggest keratitis – the identification of S. dysgalactiae in the blood, synovial fluid, and vitreous supports systemic spread as the more likely etiology. Additionally, the rapid onset of posterior segment involvement and concurrent septic arthritis strengthen the case for hematogenous seeding. Still, it is possible that anterior segment inflammation, especially in an immunocompromised host, could have facilitated intraocular penetration or masked early systemic involvement. This diagnostic ambiguity stresses the importance of a broad differential and prompt systemic evaluation in rapidly progressive ocular infections.

The patient’s liver cirrhosis and B-cell lymphoma likely contributed to his susceptibility to systemic infection. Cirrhosis impairs immune function and increases the risk of bacteremia, while lymphoma may compromise humoral immunity. These conditions, along with his recent dental extraction, may have facilitated hematogenous spread of S. dysgalactiae to both the eye and joints.

Notably, the patient was also found to have a dislocated IOL, which was first clearly identified on MRI. There was no documentation of prior complicated cataract surgery or ocular trauma. The dislocation may have resulted from zonular instability exacerbated by advanced age and severe intraocular inflammation. Additionally, the patient’s comorbidities, particularly cirrhosis and B-cell lymphoma, may have contributed to compromised ocular tissue support or repair mechanisms, predisposing him to spontaneous IOL dislocation.

Few published reports have identified S. dysgalactiae as a cause of panophthalmitis. In a case reported by Hagiya et al. [5] the infection spread hematogenously and progressed rapidly despite antibiotic therapy, resulting in evisceration. Our case is notable not only for the rare ocular involvement but also for concurrent septic arthritis, with S. dysgalactiae isolated from the eye, blood, and synovial fluid, an unusual combination not previously described. This report underscores the potential for widespread dissemination of this pathogen and highlights the importance of systemic evaluation, especially in immunocompromised patients.

Notably, an 18-mm acrylic sphere was implanted during the same surgery as the evisceration. This procedure was performed approximately 2 months after hospital discharge, once the acute infection had fully resolved. Given the absence of orbital cellulitis or abscess and the patient’s clinical stability at the time of surgery, primary placement of the implant was deemed appropriate and carried minimal risk of postoperative infectious complications.

Key lessons from this case include the Panophthalmitis warrants a systemic infection workup, particularly when unusual pathogens are identified.Third nerve palsy and a frozen globe may signal severe posterior involvement or cavernous sinus thrombosis [7], necessitating immediate neuroimaging.When visual recovery is no longer possible and the patient experiences chronic pain, evisceration remains an important therapeutic option [6].

The CARE Checklist has been completed by the authors for this case report and is attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000547764).

Conclusion

This case underscores the importance of early recognition and aggressive management in rare ocular infections such as panophthalmitis caused by S. dysgalactiae. Given its potential for hematogenous dissemination and rapid deterioration, maintaining a high index of suspicion and performing a comprehensive systemic evaluation are critical for optimizing patient outcomes.

Additionally, this case highlights the diagnostic complexity of panophthalmitis, where atypical pathogens may present with non-specific ocular symptoms, delaying recognition and treatment. Despite aggressive systemic and intravitreal antibiotic therapy, surgical intervention was ultimately required. Clinicians should remain vigilant for systemic involvement in cases of rapidly progressive panophthalmitis, ensuring prompt diagnosis, a thorough workup, and individualized management strategies to improve patient outcomes.

Statement of Ethics

Ethical approval was not required for this case report in accordance with institutional guidelines. Written informed consent was obtained from the patient for publication of this case and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.

Conflict of Interest Statement

The following authors have no conflicts of interest, including financial L.G., M.E.

Funding Sources

No funding or grant support was received for this project.

Author Contributions

Lucas Goetz contributed to the conception, drafting, and revision of this manuscript. Michael Eide has contributed to the conception, drafting, and revision of this manuscript. Both authors have read and approved the final version.