Case Presentation: A 40-year-old female with hemoglobin SC disease presented with a 2-day history of severe headache and progressive vision loss. On initial evaluation, she was febrile to 100.8 F and tachycardic. Her exam was significant for nuchal rigidity, bilateral dilated nonreactive pupils, and visual acuity left eye hand motion and right eye light perception. A lumbar puncture was performed revealing a white blood cell count of 2610 /UL with 89% neutrophils, protein 1054 mg/dL, glucose <5 mg/dL. Cerebrospinal fluid cultures grew pan-sensitive Streptococcus pneumoniae. The patient was started on ceftriaxone and dexamethasone for bacterial meningitis. Ophthalmology was consulted with their exam concerning for bilateral endogenous endophthalmitis. Anterior chamber tap was done and intraocular injections with vancomycin, ceftazidime, and dexamethasone started. Cultures of vitreous fluid from both eyes also grew S. pneumoniae. Systemic levofloxacin was added for improved ocular penetration. Despite treatment, patient’s vision deteriorated to light perception in both eyes. She continued to have intermittent fevers, however, blood cultures drawn on admission and during the hospitalization remained negative. A repeat lumbar puncture showed improvement of white blood cell count to 62 /uL, protein 101 mg/dL, glucose 55 mg/dL. Given persistence of symptoms, patient ultimately underwent bilateral vitrectomy, however, did not achieve any recovery of vision on discharge.
Discussion: Endogenous endophthalmitis is an ophthalmologic emergency resulting from bacterial seeding of the eye during bacteremia. The most common cause of bacteremia leading to endophthalmitis in the United States is endocarditis. Only a few cases of endophthalmitis from meningitis have been reported and bilateral endogenous endophthalmitis as a result of this is even more uncommon. The main components of treatment include vitrectomy, intravitreal and systemic antibiotics. Results from the Endophthalmitis Vitrectomy Study on patients with post-cataract endophthalmitis suggest that vitrectomy is superior to vitreous tap in severe disease (light perception only). However, similar studies have not yet been done in endogenous endophthalmitis. The role of systemic corticosteroids also remains controversial. Prompt diagnosis is crucial for timely initiation of treatment, although prognosis can often be poor. Our patient had significant vision loss on presentation, however, early vitrectomy could not be done due to initial severity of symptoms from meningitis. Despite treatment with corticosteroids and antibiotics, she unfortunately did not have improvement in vision.
Conclusions: Our patient demonstrates a rare case of bilateral endogenous endophthalmitis from pneumococcal meningitis that resulted in a poor outcome. Endogenous endophthalmitis should be considered in patients with symptoms of vision loss in all settings of potential bacteremia to facilitate timely treatment, and early vitrectomy should be considered in cases of severe symptoms.
To cite this abstract:Wang, TZ; Deseda, J; Kim, G; Chernyavsky, S . A CASE OF BILATERAL ENDOGENOUS ENDOPHTHALMITIS FROM PNEUMOCOCCAL MENINGITIS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 783. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-bilateral-endogenous-endophthalmitis-from-pneumococcal-meningitis/. Accessed September 23, 2019.