Endophthalmitis secondary to dialysis access-related bactere
The present case has been reported in the American Journal of Medicine.

A 73-year-old man with a history of end-stage renal disease (on hemodialysis for 6 years), hypertension, and diabetes mellitus type 2 presented with worsening pain and swelling of the left upper extremity brachiocephalic arteriovenous fistula. The patient was having night sweats for a few days prior to presentation. He was started on intravenous cephalosporin therapy at his outpatient dialysis unit as the blood cultures grew Staphylococcus aureus.

On examination, the fistula was hard, and there was skin degeneration with oozing in the area which appeared to be a pseudoaneurysm (Figure, left panel). Computed tomography scan of the arm with contrast demonstrated approximately 4.3-cm mid-segment thrombus in the arteriovenous fistula that was likely infected. The patient also complained of worsening blurry vision and left eye redness and pain. Ocular examination revealed conjunctival hyperemia and pus in the anterior chamber (hypopyon) with poor red reflex (Figure, right panel).

These findings were suggestive of endogenous endophthalmitis in the setting of dialysis access-related bacteremia, later confirmed by B-scan ultrasound. He was treated with intravitreal vancomycin and cefazolin in addition to systemic antibiotics. The arteriovenous fistula was ligated with excision of the infected pseudoaneurysm and the clot for source control.

Lessons learnt:-
• Staphylococcus aureus and Streptococci are the most common pathogens implicated in endogenous bacterial endophthalmitis. Although extremely rare, it can occur as an isolated metastatic complication of arteriovenous fistula infection, as in this case.

• It is primarily a clinical diagnosis supported by culture of intraocular fluids, although a negative culture occurs in approximately 30% of the cases.

• Timely administration of intravitreal antibiotics with or without vitrectomy is the mainstay of therapy.

• The best visual outcomes usually occur in cases caused by coagulase-negative staphylococci, and the worst outcomes are in those cases caused by streptococci, Bacillus species, and fungi.

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