A Rare Case Of Ralstonia Endophthalmitis Mimicking As Indolent Fungal Endophthalmitis

This case report intends to highlight a rare instance of indolent endophthalmitis, assumed to be fungal in origin, but later diagnosed as a case of Ralstonia mannitolilytica endophthalmitis.

This is a case report of a 56 year-old, female patient that presented to our hospital with indolent endophthalmitis one month after uneventful cataract surgery. She was complaining of decreased vision, pain and photophobia one month after cataract surgery. She was diagnosed with endophthalmitis and posted for vitrectomy.

A 56 year-old female presented to our tertiary care centre with the complaints of blurring of vision, pain and
photphobia in right eye. She had undergone right eye phacoemulsification with posterior chamber IOL implantation one
month ago and was non-compliant with her post-operative medications. On examination, her vision was found to be
perception of light (PL) with inaccurate PR. The IOP was measured to be 13 mm HG in right eye. There were cells and
flare in the anterior chamber with obscuration of fundal glow. B-scan of te right eye revealed moderate vitreous echoes
suggestive of vitreous exudates. A decision for promt pars plana vitrectomy with culture and sensitivity of vitreous sample
was decided upon. Intraoperative picture was suggestive of fungal endophthalmitis with whitish lesions on the surface of the retina.
However, the vitreous sample was negative for fungal elements. Instead, a rare organism i.e. Ralstonia mannitolilytica
was isolated. It was found to be sensitive to Co-trimoxazole. The patient was started on oral Co-trimoxaziole along with
topical medications. his led to a resolution in anterior chamber flare and exudates over the IOL slowly disappeared. The
patient's vision improved to 3/60 within a week of starting oral anti-microbial therapy.

Indolent endophthalmitis can be caused by rare organisms as in our case. Previous reports have stated endophthalmitis due to Ralstonia picketti, this is the first case report on endophthalmitis caused by Ralstonia mannitolilytica. This can be attributed to emerging multi-drug resistance in individuals. The indolent presentation can be misleading and one can assume fungal etiology and treat empirically along those lines. Therefore, a culture and sensitivity test of the vitreous sample collected should be stressed upon and carried out with utmost care to yield good results.