From New York University, New York, New York.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Shantan Reddy, MD, New York University, 530 First Avenue, HCC 3B, New York, NY 10016. E-mail: firstname.lastname@example.org
Meningitis is a serious illness that causes significant morbidity and mortality worldwide. Common etiologies include viruses, bacteria, fungi, medication, and malignancy.1 The clinical presentation of meningitis is reflective of its pathophysiology. Generalized malaise, fever, and myalgia are typical nonspecific findings related to systemic infection. Meningitis results when infection crosses the blood–brain barrier, causing an acute inflammatory reaction of the meninges and subarachnoid space.2 Ocular manifestations of meningitis are diverse and include cranial nerve palsies resulting in ocular motility dysfunction and papilledema secondary to increased intracranial pressure. Visual complaints more commonly occur in advanced disease and are typically not useful in initially identifying high-risk patients. We describe a case of aseptic meningitis with retinal hemorrhages as a presenting sign.
A 28-year-old immunocompetent woman was admitted by neurology with a 3-day history of subjective bilateral lower extremity weakness and a 2-day history of lower back pain, lower extremity arthralgias, and vesicular rash over her neck and upper chest across multiple dermatomes (Fig. 1). The patient’s ophthalmic symptoms began the day prior to admission and prompted her to come to the hospital. These symptoms included bilateral blurry vision with visual acuity of 20/30 in both eyes, mild retro-orbital pain on the right, and bilateral central vision scotomas. She had no history of neurologic or ocular disease. She reported two trips to upstate New York where she spent some time in the woods. She denied any bug bites or rashes during or immediately following those trips. On presentation, the patient had a low-grade fever of 100.4°F. She denied photophobia, neck stiffness, or mental status change.
Figure 1. A 28-year-old woman presenting with vesicular rash over neck and upper chest spanning multiple dermatomes.
Laboratory data were unremarkable except for a 10,500 white blood cell count with 81% neutrophils. A head computed tomography scan and brain magnetic resonance imaging on the day of admission were both normal. A lumbar puncture was performed the following day with normal opening pressure. Analysis showed 23 white blood cells with 80% lymphocytes, 762 red blood cells, total protein 77 mg/dL, and glucose 51 mg/dL. Lumbar puncture results were consistent with aseptic meningitis from a likely viral etiology. Erythrocyte sedimentary rate and C-reactive protein were elevated at 59 and 80, respectively. Cultures of the skin lesions grew no organisms. Intravenous acyclovir was initiated for possible varicella-zoster virus etiology. Epstein–Barr virus testing was consistent with convalescent Epstein–Barr virus infection. Other serum tests were unremarkable except for normal immunity mumps and varicella-zoster virus titers. The patient was switched to oral valacyclovir after a negative varicella-zoster virus IgM level.
Ophthalmology was consulted in light of the patient’s visual symptoms. Dilated fundus examination revealed small macular intraretinal hemorrhages bilaterally (Fig. 2). Fluorescein angiogram revealed bilateral small vessel vasculitis (Fig. 3). The reported visual disturbance was attributed to bilateral intraretinal hemorrhages likely secondary to small vessel vasculitis. The patient was discharged after 4 days with a diagnosis of aseptic meningitis of viral versus vasculitis etiology. She returned 1 month later with an improvement in visual acuity to 20/20 in both eyes and a resolution of her scotomas and retinal hemorrhages. Fluorescein angiography revealed no leakage and no residual ophthalmic abnormalities were appreciated. Valacyclovir was then discontinued.
Figure 2. (A) Fundus photograph showing small intraretinal macular hemorrhages in the right eye. (B) Fundus photograph showing small intraretinal macular hemorrhages in the left eye.
Figure 3. (A) Fluorescein angiogram showing small vessel vasculitis in the right eye. (B) Fluorescein angiogram showing small vessel vasculitis in the left eye.
We present one of the few cases of retinal hemorrhage in meningitis. Retinal hemorrhages are an uncommon finding in meningitis. The literature describes retinal hemorrhages among critically ill patients with bacterial meningitis and only in patients with significantly progressive disease. To the best of our knowledge, this is the only example where retinal hemorrhages were a presenting and diagnostic sign for meningitis.
There are many potential ocular complications of meningitis, including permanent vision loss and even blindness. Motility abnormalities are commonly due to third, sixth, and seventh cranial nerve palsies. The fourth and fifth cranial nerves are rarely involved.3,4 Meningitis is associated with increased intracranial pressure that can cause papilledema and secondary optic atrophy. Common pupillary manifestations include sluggishness and constricted or dilated nonreactive pupils.5 Lateral gaze and nystagmus occur rarely.6 Complications involving the conjunctiva, cornea, and eyelids have also been described.7,8 The fundus is affected in 5% of cases.9 The most commonly reported fundus manifestations of meningitis include temporal pallor,9,10 optic neuritis,9,10 papilledema,9,10 disc atropy,9,10 endophthalmitis,11–16 panophthalmitis,17,18 choroidal tubercles,9,10 and chorioretinitis.9,10,19 A study by Hanna et al. reported that most severe fundus complications were detected in patients with tubercular meningitis.9
Because retinal hemorrhages are rare in meningitis, they predominantly have been reported with meningococcal septicemia.20 Even in fulminant cases of meningococcal meningitis, there are usually fewer than 20 hemorrhages.21 Dinakaran et al. published a study of children with meningococcal septicemia and disseminated intravascular coagulation where 42% of the children had fewer than 20 retinal hemorrhages.21 Only 6 other previous case reports exist in the literature documenting retinal hemorrhages in association with meningitis and all of the patients except one were aged 16 days to 13 years.20,22–26
Definitive diagnosis is made by lumbar puncture. The history and physical examination serve to identify patients at high risk for meningitis who should undergo this invasive procedure. Although clinical training has emphasized the use of physical findings for early detection of meningitis,27,28 the accuracy of commonly used signs of meningeal irritation has been questioned.2,29,30 Better means for clinical bedside diagnosis are needed.29 To the best of our knowledge, our case is the first report of aseptic meningitis with retinal hemorrhage as a presenting sign early in the course of the disease. Consideration of meningitis may be an important adjunct to the work-up for adult patients presenting with retinal hemorrhage.
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