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Editor,—We report a previously well 17-year-old man who presented with a 1 day history of misty vision, pain in the right eye, and hypopyon. This latter proved to be due to metastatic meningococcal endophthalmitis. Despite appropriate therapy, the vision deteriorated to perception of light only in a matter of days, with no recovery of function.
Metastatic endophthalmitis is a rare presentation of meningococcal septicaemia, and should be considered in the differential diagnosis of a rapid onset hypopyon uveitis, even in a well patient.
This young man’s case was extremely unusual. The patient had demonstrable systemic meningococcal infection, and yet was well and apyrexial at presentation, and throughout his admission.
A 17-year-old man was referred to eye casualty by his general practitioner, with a 1 day history of misty vision and pain in the right eye, which was unresponsive to topical antibiotics. His general practitioner had noted myalgia and arthralgia with a sore throat 4 days previously, the patient had felt transiently feverish, but had apparently remained apyrexial and was otherwise well. There was nothing else in the history of note, in particular no past ocular or medical history, and on direct questioning there had been no sexual contacts or intravenous drug use.
On examination the vision was hand movements in the right, and 6/5 in the left. He had a very injected right eye, with an oedematous cornea, a 2.4 mm hypopyon, fibrin in the anterior chamber, and the pupil was bound down with posterior synechiae. There was no view of the fundus, and there was no afferent pupillary deficit. The left eye and intraocular pressures were normal.
Systemically he was apyrexial with a normal blood pressure, a pulse of 80, and a normal neurological examination without meningism. There was no ulceration of the mucous membranes. He was found to have a fading vesicular rash over his feet and ankles.
He was admitted and treated for the very acute anterior uveitis, with subconjunctival Betnesol (betamethasone) and mydricaine and subsequently with hourly drops of Pred Forte (prednisolone) and twice daily atropine 1%. Investigations revealed a slightly raised white cell count and raised inflammatory markers (erythrocyte sedimentation rate and C reactive protein). The rash was biopsied and shown to be vasculitic in nature. Blood cultures, viral titres, and urine were also sent for analysis but all were negative. He seemed to improve over the next 24 hours.
At 48 hours from presentation, the patient had developed a dense right afferent pupillary defect, and the vision was reduced to perception of light in this eye. Orbital x ray and B scan ultrasonography were unremarkable and a diagnostic vitrectomy was performed; vancomycin 2 mg, ceftazidime 2 mg, and amphotericin 5 μg were administered intravitreally. Initial microscopy of the vitreous sample revealed no infective agents, but the following day a single Gram negative diplococcus was isolated, assumed to be Neisseria meningitidis. The patient was commenced on intravenous penicillin 2.4 g six times daily, and oral rifampicin 600 mg twice daily, with intensive topical cefuroxime and gentamicin Forte eyedrops. The organism was cultured and confirmed as N meningitidissensitive to gentamicin, cefuroxime, penicillin, and chloramphenicol. Further blood cultures and throat swabs failed to grow any bacteria.
After 7 days of intravenous antibiotics under the joint care of ophthalmologists and physicians, the patient was allowed home, and topical treatment was gradually reduced over the next few weeks.
The right eye remained comfortable, with a clear cornea, a quiet anterior chamber, and a dense cataract. Vision was vague perception of light, and the dense relative afferent pupillary defect persisted; the retina remained flat on B scan ultrasonography.
Meningococcal infections can present as a spectrum of disorders from fulminant septicaemia with meningitis to infections of individual systems.
Endophthalmitis may be exogenous or endogenous. Before the modern antibiotic era, the most common form of endophthalmitis was endogenous meningococcal disease, occurring in about 5% of meningococcal cases.1 Recently, endogenous endophthalmitis is more commonly seen in immunocompromised patients, diabetics, and intravenous drug users and N meningococcus has been replaced byBacillus cereus as the leading causative bacterial agent. Even so, metastatic bacterial endophthalmitis is relatively unusual, with 72 reported cases between 1976 and 1985, eight of these were caused by N meningitidis2 Since then only five other cases have been attributed to N meningitidis.3-6
Most of these cases describe patients who are systemically unwell, with fulminant septicaemia, or pyrexia with meningitis or with concurrent gastrointestinal or musculoskeletal symptoms. There have been only a few cases described where the systemic illness has been less dramatic or where the patients have not been unwell at the time of presentation.
Auerbach et al in 1989 presented a 13-month-old boy with endophthalmitis, a spontaneously resolving rash, and a persistent pyrexia where N meningitidis was found in the vitreous but not blood.4 Residual vision was slight after appropriate topical and intravenous antibiotics, but diagnosis was delayed by the atypical presentation. Brisner and Hess in 1981 described a 15-year-old girl with a rash and arthralgia which had resolved by the time eye symptoms and endophthalmitis developed.3 She remained slightly pyrexial. N meningitidis was isolated from the aqueous and vitreous,but not from the blood. She was left with HM vision and a dense cataract. Kearns and Sprott in 1991 presented a similar case, where a 23-year-old man had pyrexia and myalgia only at the time of presentation with his eye symptoms and endophthalmitis, but who despite appropriate therapy was left with perception of light vision only in the affected eye.5 Abousaesha et al presented a case of a man unwell at presentation with GI symptoms and with positive blood cultures, who developed a rash after presentation with endophthalmitis. This patient had a final visual acuity of 6/12.6
Our patient was very unusual in being well at presentation, despite having had a systemic meningococcal infection. He had negative blood cultures and he remained apyrexial throughout. He had myalgia and a rash several days before presentation which presumably represented a bacteraemic event.
These cases demonstrate the occasional atypical presentation of metastatic meningococcal endophthalmitis. We should be aware of this diagnosis, even in seemingly systemically well patients, as the visual outcome is often poor despite aggressive and prompt therapy.