Case Report 34.149x
Download
Report
Transcript Case Report 34.149x
Bilateral Endogenous Bacterial
Endophthalmitis and Bacteraemia as
the presenting manifestation of
Multiple Myeloma.
Peter Cikatricis 1, 3
Korina Theodoraki 1
Yit C.Yang 3, 4
Alastair K.O. Denniston 1, 2, 3
1 Queen
Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
2 Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
3 Wolverhampton Eye Infirmary, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
4 Aston University, Birmingham, United Kingdom
Ocular History
59-year old Caucasian male
12/2013 - 6-day history of painless decrease of
vision in both eyes (L > R)
Headache, Fever, Nausea and Vomiting
POcHx: Left strabismic amblyopia (20/40 BCVA)
PMHx: Dental work 2 weeks prior, ex-smoker
DHx: Nil
First Clinical Presentation
Bilateral asymmetric vitritis with left panuveitis
Fundus infiltrative lesions (OS and ?OD)
Systemic signs of infection
Examination at First Presentation
Fever
39.5 °C (103.1°F)
Tachycardia
122 bpm
Auscultation
Grade 4/6 Pan-systolic murmur
EYE
Right
Left
BCVA
20/40
HM
A/S & IOP
Unremarkable, 12
Ciliary injection, 14
A/C
Cells +, Flare +
Cells 2-3+, Hypopyon
Pupil
Reactive/No RAPD
PS++
Lens
Clear
Clear
Right Eye
Vitreous
Fundus
Few Cells
Roth spots?
minimal exudate
Left Eye
Vitreous
Fundus
Marked vitritis
(Grade 4 haze)
Very limited view
Differential Diagnoses
Infection:
Inflammation: Masquerade:
Bacterial
Atypical
Sarcoidosis
Viral
HIV/Syphilis Severe HLAB27-ass.
Toxoplasmosis
Fungal
Lymphoma
Other blood
malignancies
Paraneoplastic
Initial Investigations
Bloodwork (CBC, biochemistry, ESR, CRP,
ACE, Ca2+, ANA, ANCA, TPHA, HIV,
Toxoplasma, Borrelia, TB T-Spot)
Blood cultures
CT/MRI of head and chest
Trans-oesophageal Echocardiogram requested
Lab Results
ESR – 62 mm/h (<30)
CRP – 246 mg/L (<10)
white blood cell count – 14.2 x109/L (4.00-11.00)
neutrophils – 12.1 x109/L (2.5–7.5)
all serology negative but…
Streptococcus Pneumoniae (Serotype 23B)
in blood cultures, possible sources:
recent dental work
bacterial endocarditis
Transoesophageal echocardiogram: mobile mass at the
mitral valve (central on the video below)
severe, posteriorly directed jet of mitral regurgitation
(light blue flow below)
normal
Transoesophageal
echocardiogram
Diagnosis
Pneumococcus endogenous endophthalmitis
Caused by Pneumococcal bacteraemia from
endocarditis
Initial Treatment
IV Vancomycin 1g STAT
IV Meropenem 1g STAT
Intravitreal Vancomycin 2mg – R & L
Right Eye
20/15
NAD
Resolution
Left Eye
20/120
Reduced hypopyon
Vitritis - Grade 3
Vitreous haze
Hospitalised for intravenous
antibiotics:
IV Vancomycin 1g BD
Meropenem 1g TDS
In 3 weeks prepared for
therapeutic mitral valve
replacement – 31mm valve
implanted
However the story continued...
Screening for possible underlying
immunosuppression was negative for HIV but ..
Elevated paraproteins – 33.2 g/L (>30 g/L)
diagnostic of multiple myeloma
bone marrow biopsy confirmed:
IgG-Multiple Myeloma
Bone Marrow Biopsy
Histopathology
Skeletal Survey
Low power view
of bone marrow
High power view
of plasma cells
CD138 immunohistochemistry
staining of
plasma cells
Lucencies seen in the proximal femoral
shafts, within L5, in the mid-humeral
shaft
Further Treatment
4 weeks after initial presentation discharged from
hospital
Good cardiac and systemic recovery
VA at discharge:
20/15 OD
20/40 OS (recovery of his normal level of
vision in amblyopic eye)
Control after 8 weeks
Left eye
retinal detachment
treated by ppvitrectomy/cryo/gas
final visual outcome at 4 months:
20/15 OD
20/80 OS (due for cataract surgery)
Final Diagnosis
Bilateral endogenous pneumococcal
endophthalmitis, caused by endocarditis
Multiple Myeloma predisposed the patient to
develop bacterial endocarditis
first case described in the literature
Conclusion
The onset of Multiple Myeloma is often insidious
It is of utmost importance to ascertain underlying
diagnosis of bilateral endophthalmitis in timely
fashion in order to deliver effective treatment
Haematological malignancies should be
considered as one of the causes of acquired
immunosuppression in cases of endogenous
endophthalmitis