PMC9522998_01
The graphs of his systemic inflammatory markers during his admission at the local hospital. In the initial phases of his admission, there is elevation of lactate dehydrogenase, serum ferritin, and D-Dimer with peak levels between 11 and 14 days after diagnosis of COVID-19. Other parameters such as white blood count, absolute neutrophil count, urea, uric acid, and creatinine levels were also high except CRP which was lower during the same time.
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F1
Figure 1 shows the graph of inflammatory markers during his admission at a local hospital.
(a) Diffuse slit-lamp view of the right eye showing circumcorneal congestion and chemosis, with hazy cornea anterior chamber flare 4+ cells 3+, exudates, and 2 mm hypopyon, with exudates in the pupillary area. (b) Ultrasound B scan of the right eye shows medium reflective echoes with organized vitreous debris and membrane in the entire vitreous with a pre-retinal mass.
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F2
The right eye had lid edema, ciliary congestion, corneal epithelial edema, Descemet's membrane folds, stromal edema, and anterior chamber had flare 3+, cells 3+ with a hypopyon of 2 mm with membranes in the pupillary area and over the lens (Fig. 2a). Ultrasound B-scan of OD showed medium-high reflectivity echoes on vector A scan corresponding to dense vitreous debris predominantly in the middle and posterior vitreous cavity (Fig. 2b). Figure 3a shows nested PCR in 2% agarose gel with positive eubacterial genome in well 3 and 4.
(a) Nested polymerase chain reaction in 2% agarose gel showing four wells from left to right, Well 1 - negative control; Well 2 - sample showing positive; Well 3 - second round positive control; and Well 4 - first round positive control. (b) Pseudomonas aeruginosa colony growth in nutrient agar showing greenish tinged colonies.
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Figure 3a shows nested PCR in 2% agarose gel with positive eubacterial genome in well 3 and 4. Figure 3b shows Pseudomonas aeruginosa colonies in nutrient agar showing greenish tinged colonies from the urinary sample.
(a) Wide angle fundus images of the right eye (top) 2 weeks after surgery showing pre-retinal exudates and subretinal fluid in the macular area and (down), (b) 1 month later showing reduction of the pre-retinal exudates.
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OD was counting fingers at 1 m. OD showed conjunctival congestion, anterior chamber flare 2+, cells+, pigments, pigment clumps on the lens, vitreous haze 2+ cells +, pre-retinal exudate, subretinal fluid, and exudates in the macular area (Fig. 4a). A month later, after treatment with systemic, topical intravitreal antibiotics he had reduced pre-retinal exudates (Fig. 4b).
(a) SD-OCT of the right eye (top) 2 weeks after surgery showing pre-retinal hyper-reflectivity with shadowing of the retina and choroid, while adjacent to it shows inner retinal swelling and mild subretinal fluid and (b) (down) 1 month later showing reduction in the same.
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Spectral domain optical coherence tomography (SD-OCT) of OD showed pre-retinal hyper-reflectivity with shadowing of the retina and choroid, while adjacent area showed inner retinal swelling and mild subretinal fluid (Fig. 5a). SD-OCT a month later showed reduction in subretinal fluid and inner retinal swelling (Fig. 5b).
(a) Gangrene at the root of the nose (vertical stout down arrow Figure 6a) and presence of purpuric rash beneath it suggesting inflammation (block red arrow) and eschar-like lesions on the forehead (hollow red arrow). (b) Healed gangrene and reduction of eschar a month later.
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F6
Another characteristic feature in our patient at the time of ocular presentation was the presence gangrene at the root of the nose (vertical stout down arrow (Fig. 6a)) and presence of purpuric rash beneath it suggesting inflammation (block red arrow) and eschar-like lesions on the forehead (hollow red arrow). Figure 6b shows healed gangrene and reduction of eschar a month later.