LETTER TO THE EDITOR

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in the left eye. The patient did not know there was a con-tact lens retained in her left eye. Slit lamp biomicroscopy of

However, several reports have demonstrated an associationbetween certain bacterial species and a specific color of in-

Stefater et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:9 DOI 10.1186/s12348-015-0041-4patients with urinary tract infections [3,4].Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, HarvardMedical School, 243 Charles Street, Boston, MA 02114, USAthe left eye revealed diffuse corneal edema with a largepericentral epithelial defect (5.2 2.7 mm) with three smallfocal areas of infiltration measuring less than 1 mm, 4+ celland flare, and a 1-mm hypopyon. The rest of the exam wasunremarkable. At this time, the patient was presumed to

traocular infiltration. A pink hypopyon was first reported asa sign of S. marcescens endophthalmitis [2]. A subsequentreport also identified Klebsiella pneumonia endophthalmi-tis as a cause of pink hypopyon [3]. Interestingly, the S.marcescens bacterium has been known for many years toproduce a red pigment (prodigiosin). The red pigment hasbeen identified in tooth abscesses and in the urine of* Correspondence: James_Chodosh@meei.harvard.eduher prophylactic oral acyclovir 400 mg twice daily. Herother medical problems include lumbar disk herniation,hypertension, gastroesophageal reflux disease, and cir-rhosis secondary to alcohol use.On exam, the patient was found to have normal vital

signs. Her best corrected visual acuities were 20/40 in theright eye and 20/300 in the left eye. Anterior examinationof her right eye was unremarkable except for a mild nuclearsclerotic and cortical cataract. On the left, she was noted tohave erythema and tenderness of her eyelids with 3+ diffuseconjunctival injection. She had a soft contact lens in place

have improved symptoms but unchanged visual acuity.Exam revealed an improving epithelial defect and diffusecorneal stromal haze with moderate folds in Descemetsmembrane. The patient now had a 2-mm hypopyon thatwas distinctly pink in color (Figure 1). Cultures were subse-quently positive for Serratia marcescens from both thecorneal scrapings and the retained contact lens.In a recent report, S. marcescens makes up about 10% of

culture isolates in bacterial keratitis [1]. Initially, we pre-sumed that the pink nature of the hypopyon was secondaryto coincident red blood cells with the leukocyte infiltrate.Pink hypopyon in a patiemarcescens corneal ulceraJames A Stefater, Durga S Borkar and James Chodosh*

Abstract

A 65-year-old woman presented to the emergency wardof redness, irritation, photophobia, and diminished visioncorneal ulcer with a small hypopyon. On the following dpatient had improved symptoms but now had a 2-mm hpositive for Serratia marcescens. A pink hypopyon, a rareEnterobacteriacae, either Klebsiella or Serratia. Immediate

Keywords: Corneal ulcer; Pink hypopyon; Serratia marces

A 65-year-old woman presented to the emergency wardat the Massachusetts Eye and Ear Infirmary with 2 daysof redness, irritation, photophobia, and diminished vi-sion in her left eye. She wore soft contact lenses butnoted that she had not worn her lenses for the last 3days. She also described a prior history of ocular herpessimplex virus in both eyes which last flared 7 monthsprior to her presentation. She noted compliance with 2015 Stefater et al.; licensee Springer. This isAttribution License (http://creativecommons.orin any medium, provided the original work is pOpen Access

t with Serratiation

the Massachusetts Eye and Ear Infirmary with 2 daysher left eye. She was found to have a large central

, after initiation of broad-spectrum antibiotics, theopyon that was distinctly pink in color. Cultures werecurrence, alerted the authors to a causative agent ofd intensive treatment was subsequently initiated.

ns

have contact lens-related keratitis with concern for herpessimplex virus reactivation. A corneal scraping was per-formed for gram and calcofluor white stains and cultures,and the contact lens was also cultured. The patient wasstarted on acyclovir 400 mg PO five times daily, cyclopen-tolate three times daily, fortified vancomycin 25 mg/mlevery hour, and tobramycin 14 mg/ml every hour.Upon return the following day, the patient was found toan Open Access article distributed under the terms of the Creative Commonsg/licenses/by/4.0), which permits unrestricted use, distribution, and reproductionroperly credited.

Stefater et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:9 Page 2 of 2In this report, we describe a case of a pink hypopyoncaused by a contact lens-related corneal ulcer. Our pa-tient responded well to immediate and intensive treat-ment with fortified aminoglycosides. A pink hypopyonshould alert the physician to a causative agent thatincludes Enterobacteriacae, either Klebsiella or Serratia,and can occur in relation to contact lens over-wear.

ConsentWritten informed consent was obtained from the patientfor the publication of this report and the accompanyingimage.

Competing interestsThe authors declare that they have no competing interest.

Authors contributionsJAS, DB, and JC conducted the clinical diagnosis and decision-making. Allauthors read and approved the final manuscript.

Figure 1 The patients left eye demonstrating a pink hypopyonin the presence of fluorescein staining.AcknowledgementsNone.

Received: 31 December 2014 Accepted: 19 March 2015

References1. Kowalski RP, Kowalski TA, Shanks RM, Romanowski EG, Karenchak LM, Mah

FS (2013) In vitro comparison of combination and monotherapy for theempiric and optimal coverage of bacterial keratitis based on incidence ofinfection. Cornea 32:830834

2. Al Hazzaa SA, Tabbara KF, Gammon JA (1992) Pink hypopyon: a sign ofSerratia marcescens endophthalmitis. Br J Ophthalmol 76:764765

3. McEntegart MG, Porterfield JS (1949) Bacteremia following dentalextractions. Lancet ii:596598

4. Kass EH, Schneiderman LJ (1957) Entry of bacteria into the urinary tracts ofpatients with inlaying catheters. N Engl J Med 256:556557Submit your manuscript to a journal and bene t from:

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AbstractConsentCompeting interestsAuthors contributionsAcknowledgementsReferences