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Arch Ophthalmol. 2002;120:1093-1094.

Infectious scleritis, typically occurring in eyes having predisposing risk factors, is vision-threatening. We present a case of infectious scleritis after chemotherapy, which, to our knowledge, has not been previously reported as a risk factor.

Report of a Case
A 58-year-old woman manifested symptoms of a red, painful right eye for 1 day. Four months previously, she had undergone right mastectomy for breast cancer and was receiving chemotherapy with cyclophosphamide and epidoxorubicin. She had completed the fifth course of chemotherapy 3 weeks before this visit. Her medical history, including surgery and trauma, was otherwise unremarkable.

At presentation, slitlamp examination showed conjunctival congestion with a 2 x 2-mm scleral nodule surrounded by episcleral vessels (Figure 1A). Other ocular findings were unremarkable. Infectious scleritis was suspected. She was placed on a regimen of fortified topical cefazolin sodium (25 mg/mL) and gentamicin sulfate (14 mg/mL) every hour and systemic gentamicin sulfate, (60 mg) every 8 hours. On the next day, we performed peritomy to verify the scleral nodule. Cultures were obtained, and the necrotic sclera was debrided and irrigated with gentamicin. A gram stain of the scleral nodule showed gram-negative rods (Figure 2). The culture report disclosed heavy growth of Serratia marcescens that was sensitive to gentamicin, amikacin, ciprofloxacin, piperacillin sodium, imipenem, ceftizoxime sodium, and ceftazidime, but resistant to cefuroxime, ampicillin, and cephalothin sodium. Therapy with topical and systemic gentamicin was continued, then tapered during the next 2 weeks until the lesion was resolved (Figure 1B). No recurrence or visual impairment was found during the 1-year follow-up.

View larger version (27K): [in this window] [in a new window] Figure 1. A, A 2 x 2-mm scleral nodule (arrow) surrounded by engorged episcleral vessels. B, The abscess subsided after debridement and antibiotic treatment.

View larger version (31K): [in this window] [in a new window] Figure 2. The gram stain from the scleral nodule showed gram-negative rods (arrowhead) (original magnification x400).

A rheumatologic evaluation performed at presentation showed normal findings. The leukocyte count was 6200/µL, with a decreased percentage of polymorphonuclear cells and lymphocytes (polymorphonuclear cells, 48%; lymphocytes, 18%). The patient's leukocyte count had been decreasing during 4 months of chemotherapy. In particular, the percentage of polymorphonuclear cells had decreased from 77% to 48%. However, there was no associated systemic infection.

Comment
Trauma and surgery are important risk factors for infectious scleritis.^1-2 Two cases of infectious scleritis without history of trauma or surgery have been reported elsewhere.^3-4 Maskin³ described a diabetic patient with infectious scleritis; the culture report was the same as that from the patient's foot ulcer. Maskin speculated it was probably due to self-inoculation. Reynolds and Alfonso⁴ reported infectious scleritis in a patient with acquired immunodeficiency syndrome. Unfortunately, a detailed history of the patient was not available. We found no known risk factors of infectious scleritis in our patient. The only possible clue was the patient's immune status. Cyclophosphamide-related bone marrow suppression applies to all elements of the bone marrow but affects leukocytes to the greatest degree.⁵ Such a condition may increase the risk of infection before suppression of neutrophil production is evident. Serious infection has been found to develop in 12% to 32% of patients receiving high-dose cyclophosphamide.⁵ In addition, epidoxorubicin also contributes to myelosuppression. In our patient, chemotherapy might have suppressed the immune system, allowing subsequent development of infection. However, we cannot identify whether the infection source was exogenous or endogenous.

To our knowledge, this is the first report of infectious scleritis after systemic immunosuppressive therapy. This case demonstrates that microbial scleritis may imitate nodular scleritis, even though there may be no history of trauma or surgery to implicate infection. The diagnosis of infectious scleritis may be delayed and mistaken for an autoimmune process. In patients at risk of infections, such as our patient who was undergoing chemotherapy, it is of primary importance to prevent devastating consequences.

AUTHOR INFORMATION

Yih-Shiou Hwang, MD; Yeong-Fong Chen, MD; Chi-Chun Lai, MD; Henry Shen-Lih Chen, MD; Ching-Hsi Hsiao, MD
Taipei, Taiwan

Corresponding author and reprints: Ching-Hsi Hsiao, MD, Department of Ophthalmology, Chang Gung Memorial Hospital, No. 199, Tung Hwa North Road, Taipei 105, Taiwan, Republic of China (e-mail: qq_hsiao{at}yahoo.com).

REFERENCES
1. Riono WP, Hidayat AA, Rao NA. Scleritis: a clinicopathologic study of 55 cases. Ophthalmology. 1999;106:1328-1333. FULL TEXT | ISI | PUBMED 2. Smith JR, Chee SP. Nodular anterior scleritis associated with ocular trauma. Singapore Med J. 2001;42:180-181. PUBMED 3. Maskin SL. Infectious scleritis after a diabetic foot ulcer. Am J Ophthalmol. 1993;115:254-255. PUBMED 4. Reynolds MG, Alfonso E. Treatment of infectious scleritis and keratoscleritis. Am J Ophthalmol. 1991;112:543-547. PUBMED 5. Buckner CD, Rudolph RH, Fefer A, et al. High-dose cyclophosphamide therapy for malignant disease: toxicity, tumor response, and the effects of stored autologous marrow. Cancer. 1972;29:357-365. FULL TEXT | ISI

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