The Viscous Clue

A 54-year-old man with poorly controlled type 2 diabetes (most recent HbA1c 10.8%) originally from Vietnam presents to the emergency department with 3 days of right eye pain, redness, and rapidly worsening vision. He reports that his vision in the right eye has deteriorated from blurry to nearly absent over the past 24 hours. He also describes 1 week of fever, drenching night sweats, and right upper quadrant discomfort that he attributed to indigestion. He has not seen a physician in over a year. He takes metformin intermittently and denies recent trauma, eye surgery, or contact lens use.

On examination he is febrile to 39.1°C with a heart rate of 112 beats per minute and blood pressure of 118/74 mmHg. He is alert and oriented. Ophthalmologic examination of the right eye reveals visual acuity of light perception only, marked periorbital edema, conjunctival injection, a hypopyon, and dense vitritis obscuring the fundal view. The left eye is unaffected with visual acuity 20/25. The remainder of the cranial nerve examination is intact. Abdominal examination reveals right upper quadrant tenderness to deep palpation without peritoneal signs; there is no jaundice or scleral icterus. No skin lesions, joint swelling, or focal neurologic deficits are identified.

Laboratory data show white blood cell count 18,400/μL with 91% neutrophils, hemoglobin 11.8 g/dL, and platelets 142,000/μL. Comprehensive metabolic panel shows glucose 318 mg/dL, total bilirubin 1.4 mg/dL, ALT 88 U/L, AST 72 U/L, alkaline phosphatase 214 U/L, and creatinine 1.1 mg/dL. C-reactive protein is 248 mg/L. Urinalysis shows 1+ glucose without pyuria. Two sets of blood cultures are drawn and sent for processing. Ophthalmology is consulted and confirms the diagnosis of endogenous endophthalmitis of the right eye. They recommend urgent intravitreal antibiotics and note that the prognosis for visual recovery is guarded.