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I read with interest the article by Berry et al. describing the occurrence of meningococcal endophthalmitis without concomitant meningitis or septicaemia. I, too, have reported a case of meningococcal endophthalmitis associated with a skin rash.but without the manifestations of meningitis.  The patient was a 15 year old boy who had been treated with penicillin by his GP, for a sore throat. He su...
I read with interest the article by Berry et al. describing the occurrence of meningococcal endophthalmitis without concomitant meningitis or septicaemia. I, too, have reported a case of meningococcal endophthalmitis associated with a skin rash.but without the manifestations of meningitis.  The patient was a 15 year old boy who had been treated with penicillin by his GP, for a sore throat. He subsequently developed a skin rash associated with a florid uveitis. This proved to be an endogenous endophthalmitis, and gram negative diplococci were demonstrated following an anterior chamber tap and vitreous biopsy. The patient was treated with intravitreal gentamicin and vancomycin, and high dose intravenous benzylpenicillin and ciprofloxacin and subsequently commenced on 60 mg oral prednisolone. Chloramphenicol and benzylpenicillin were also applied topically. However, the severity of the intraocular inflammation resulted in the development of cyclitic membranes and the eye began to appear phthisical. He subsequently underwent vitrectomy and lensectomy and visual acuity at 1 month was recorded as 6/60.
Acute meningococcal infection resulting in ocular involvement is rarely seen nowadays, due to prompt diagnosis and treatment with high dose intravenous antibiotics. Meningococcal endophthalmitis is, however, a well documented complication of endogenous meningococcal disease and was particularly prevalent in the pre-antibiotic era, occurring in around 6% of diagnosed cases of meningococcal meningitis. 
In the case which I have described, the focus of infection appeared to to have been the throat. This resulted in bacteraemia with an associated maculopapular rash, and invasion of ocular tissues via the blood/ocular barrier with resultant endophthalmitis. Blood cultures were negative, but meningococcus was cultured from the throat, and gram negative diplococci were present in samples from both the aqueous and vitreous. It is generally accepted that the causative organism in metastatic bacterial endophthalmitis can be confidently identified from positive cultures of non-ocular sites.
The poor visual outcome in these cases may be attributable to the delay in diagnosis and appropriate management of meningococcal infection. It is believed that just as alterations in the blood/brain barrier occur in meningitis, similar disruption occurs in the blood/ocular barrier.  In the case of the 15 year old, there was a past history of tonsillitis and there were no neurological signs. Initial administration of oral penicillin V may have been sufficient to help combat the focus of infection in the throat, but oral penicillin would not reach sufficient levels within the eye to combat ocular infection.
There may be a case for advocating early vitrectomy and lensectomy in the management of such cases. The poor prognosis may be associated with the development of cyclitic membranes, which can cause traction on the ciliary body, lowering the intraocular pressure and causing ciliary, choroidal and retinal detachment.
It is important to increase awareness of meningococcal endophthalmitis as a differential diagnosis in the management of children or young adults, who present with a uveitis and a skin rash, particularly during the meningococcal season, so that early diagnosis and treatment may help to prevent the disastrous sequelae which can lead to blindness.
(1) PA Berry, JK Dart, E Graham, M Matheson, EME MacMahon. Permanent visual loss in a child with a rash. Br J Ophthalmol 2003;87:515.
(2) McElvanney A. Minerva. BMJ 1994;308:730.
(3) Lewis PM. Ocular complications of meningococcal meningitis. Am J Ophthalmol 1940;23:617-632.
(4) Greenwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis: a contemporary reappraisal.Suev Ophthalmol 1986;31:81-101.