Metastatic choroidal abscess due to Pseudomonas aeruginosa in patients with cystic fibrosis.

Pseudomonas aeruginosa is regularly isolated from the lungs of patients with cystic fibrosis. However, this organism does not usually spread to involve other sites in these patients as it can in other groups of patients [1]. We describe two patients with cystic fibrosis and choroidal abscesses due to P. aeruginosa; bacteremic spread of the organism from a distant source was presumed to have occurred in both cases. Patient 1. A 22-year-old male with cystic fibrosis had undergone bilateral sequential lung transplantation. His early clinical course was uncomplicated, and his therapeutic regimen included prednisolone, cyclosporine, and azathioprine. Eight months after the procedure, he developed pneumonia. P. aeruginosa was isolated from bronchoalveolar lavage fluid, and he received intravenous antibiotics. Over the next 2 months, he had further respiratory infections requiring intravenous antibiotic therapy. Ten months after transplantation, the patient presented with sudden painless visual loss in his right eye. Examination revealed a visual acuity of 1/60, moderate vitritis, and a large, solitary subretinal mass (figure 1). A diagnostic vitreous tap was performed, and P. aeruginosa was isolated from the specimen. Intravitreal and intravenous antibiotics were administered. The abscess continued to enlarge, and external transscleral drainage of the choroidal abscess was performed on two occasions. Despite these measures, the abscess enlarged again, causing scleral pain, proptosis, and progressive retinal detachment; therefore, the eye was enucleated. Several sources of the metastatic choroidal infection were identified. Collapse and consolidation of the right-upper lung lobe were detected, and the lobe was resected. Mediastinal abscesses were identified and drained twice. A transoesophageal echocardiogram, which was obtained following a cerebrovascular event, showed a left atrial thrombus that was surgically resected. This thrombus, which may have arisen from the mediastinal abscesses and spread contiguously along a suture line, yielded P. aeuruginosa. The patient required hospitalization for 90 days, and during this period, he received multiple antibiotics. He recovered well, with no discernible neurological deficits; a blood-gas analysis showed that the arterial oxygen saturation was 97% while he was breathing room air. After discharge, he returned to his employment. Three months later the patient presented with pneumonia and sepsis, and a large splenic abscess was detected. Despite aggressive treatment, he died of sepsis, diffuse intravascular coagulopathy, and hemorrhage. Patient 2. A 23-year-old man with cystic fibrosis (complicated by deteriorating lung function [FEV i , —30% predicted], chronic P. aeruginosa lung colonization, hemoptysis, insulin-dependent diabetes mellitus, and pancreatic insufficiency) had been in stable condition and had not been hospitalized for 3 years. He presented with right eye pain and blurred vision. He had had occasional fevers