Sir,

Pink hypopyon had been reported in cases of Serratia marcescens endophthalmitis1 and leukaemia uveitis.2 We report for the first time the presentation of a pink hypopyon caused by Klebsiella pneumonia.

Case report

A 38-year-old woman experienced progressive blurred vision in the right eye for 2 days. One week earlier, she had had intermittent fever and a sore throat. She was treated with oral prednisolone 25 mg bid and topical steroid OD.

She was afebrile at the time of examination. Her visual acuity was 20/200 OD and 20/20 OS. A 1.5-mm pink hypopyon with diffuse chemotic conjunctiva, fine fibrinous exudates on the lens, and grade III vitreous opacities was found in the right eye (Figure 1a). Laboratory tests showed a white cell count of 10 × 103/μl, 2% atypical lymphocytes, and 1% band.

Figure 1
figure 1

(a) Slit lamp examination of the right eye at initial examination showing pink hypopyon with conjunctival injection and chemosis. (b) Photomicrograph of the anterior chamber aspirate shows numerous neutrophils and bacilli. (c) Orbital CT revealed panophthalmitis and right orbital cellulites with preseptal and retroorbital involvement.

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Aqueous and vitreous aspirations and intravitreal injections of vancomycin (1.0 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were performed on suspicion of infectious endophthalmitis. The aqueous aspirate showed numerous neutrophils, polymorphonuclear cells, and a few bacilli (Figure 1b). The patient was hospitalized and given intravenous vancomycin 500 mg every 6 h and ceftazidime 500 mg every 12 h. Systemic antibiotic treatment was replaced by ceftriazone 1 g every 12 h after a systemic survey revealed an abscess of 3.72 cm at segment 5 of the liver. Sonography-guided percutaneous drainage of liver abscess was performed on the second day of admission. However, panophthalmitis (Figure 1c) developed and her vision rapidly deteriorated to negative light sense. On day 3, endogenous Klebsiella pneumonia endophthalmitis was established on the basis of vitreal aspirate and liver abscess culture. Scleral melting developed and perforated at the inferior nasal sclera on day 10, and evisceration was performed. The patient was discharged after liver abscess was completely absorbed 3 weeks after admission.

Comment

Klebsiella pneumonia endophthalmitis accounts for 60% of cases of endogenous endophthalmitis in East Asia.3 Hepatobiliary infection is the most common source of bacteraemia. Rapid progression in clinical course was observed in this patient, which was initially misdiagnosed as uveitis. Klebsiella is not known to produce the red pigment, prodigiosin, which is produced by Serratia species. We speculate that this pink hypopyon is caused by Klebsiella pneumonia that tends to be destructive and leads to extensive necrosis and haemorrhage.4

In conclusion, pink hypopyon could be the initial presentation of Klebsiella pneumonia endophthalmitis, which subsequently causes a fulminant clinical course in healthy individuals. A pink hypopyon should raise suspicion of Enterobacteriaceae, either Klebsiella or Serratia, infection, which needs prompt systemic survey and appropriate antibiotic treatment.