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2. Dissaix E, Maggiore G, De Giacomo C, Mondell M, Martes P. Alvatez F. Autoimmune hepatitis in children and hepatitis C Virus testing. Lancet I99o; 335: I I6o--x I6I. 3. Carter RL. Antibody formation in infectious mononucleosis II. Other IgG antibodies and false positive serology. Br J Haematol I966; I2 : 268-275. 4- Schooley RT, Denson P, Harman D et al. Anti-neutrophil antibodies in infectious mononucleosis. Am J Med I984; 76: 85-90. 5. Christie AB. Infectious mononucleosis. In: Infectious diseases. London: Churchill Livingstone, I987: I2IO-I23O.

Endophthalmitis caused by N e i s s e r i a m e n i n g i t i d i s Accepted for publication Io September I99o Sir, W e read with interest the report by Cheesbrough et al., 1 of two cases of metastatic pneumococcal endophthalmitis. We wish to report a case of endophthalmitis caused by Neisseria meningitidis. A 23-year-old male was referred to the eye out-patient d e p a r t m e n t with a 3 days' history of pain above the left eye, photophobia and deteriorating vision. T r e a t m e n t with chloromycetin eye drops by his general practitioner had proved ineffective. T h e r e had been no trauma to the eye, but he gave a history of recent sore throat, arthralgia and myalgia. T h e patient was pyrexial and following detailed examination of the eye, a preliminary diagnosis of endophthalmitis of either inflammatory or infectious aetiology was made. After conjunctival smears had been taken, x25 m g cefuroxime and 20-40 m g gentamicin were instilled subconjunctivally. In addition the patient was prescribed M a g n a p e n I g 6-hourly orally and gentamicin forte eye drops at half-hourly intervals. Following admission to hospital, blood cultures were taken and the anterior chamber was aspirated. Microscopic examination showed numerous pus cells in the conjunctival smear but not in the aspirate. Micro-organisms were not seen in either specimen. Culture of the conjunctival smear gave a scanty growth of coagulase-negative staphylococci only, but the anterior chamber material yielded a G r a m - n e g a t i v e coccobacillus. As the anterior chamber appeared full of pus and fibrin and because the eye continued to discharge and show no red reflex, x25 m g cefuroxime was again instilled subconjunctivally, M a g n a p e n was replaced by intravenous ampicillin x g 6-hourly and, in an attempt to obtain eye tissue penetration, 2, 3 oral ciprofloxacin 500 m g x2hourly was prescribed. In addition to topical gentamicin, hourly methicillin and 8hourly atropine eye drops were added to the regimen. T h e organism was subsequently identified as N . meningitidis group C, type 2b, sensitive to penicillin, cefuroxime, gentamicin and ciprofloxacin. Accordingly, the ampicillin was increased to 2 g 6-hourly, and the methicillin eye drops were discontinued. T h r o a t and nasal swabs were taken for culture, but the organism was not isolated from these nor f r o m the blood cultures previously collected. Eight days after admission, vitrectomy was p e r f o r m e d which showed solid fibrin, and o-i m g gentamicin was injected into the eye. Despite this, visual acuity did not improve. T r e a t m e n t with oral ampicillin was continued for 7 days after which he was given prophylactic rifampicin and then discharged. T h e patient attended the out-patient d e p a r t m e n t regularly and as the eye showed no marked i m p r o v e m e n t , further courses of ampicillin and gentamicin were prescribed until at least 5 weeks of antimicrobial chemotherapy had been given. Despite this, at a follow-up appointment the eye appeared phthisical, the patient perceived only light and the prognosis was thought to be poor.

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There have been previous papers recording ocular complications in meningococcal disease, 4-v and it has been reported that endophthalmitis due to endogenous meningococcal disease occurred in about 5 % of meningococcal meningitis cases, s'9 Following a report by Brisner and Hess, 1° Auerbach et al., 11 presented the second case of endophthalmitis without concomitant systemic meningococcal infection. In our patient there was no history of exogenous infection following trauma or surgery. T h e patient's initial presentation was not as systemic meningococcal infection and blood cultures were negative. However, no specimens were taken in the acute phase and it is not possible to determine if the patient's symptoms before presentation represented haematogenous spread of the organism with, as suggested by Auerbach et al., ~ selective seeding in the eye, resulting in an endophthalmitis. Despite subsequent intensive patient management, including the administration of systemic and topical antibiotics, the sight of this patient's eye could not be saved. (We thank Mr R. Porter for permission to report this case, the MLSO staff for isolating the organism and the Public Health Laboratory Reference Centre, Manchester for serotyping the isolate.)

Public Health Laboratory, Institute of Pathology, General Hospital, Westgate Road, Newcastle upon Tyne N E 4 6BE, U.K.

.4. M . Kearns M . S. Sprott

References

I. Cheesbrough JS, Williams CL, Rustom R, Bucknall RC, Trimble RB. Metastatic pneumococcal endophthalmitis : report of two cases and review of literature. J Infect 199o; 2 o : 231-236. 2. Luthy R, Joos B, Gassmann F. Penetration of ciprofloxacin into the human eye. Proc ISt International Workshop, Leverkusen 1985 ; 192-196. 3. Fern AI, Sweeney G, Doig M, Lindsay G. Penetration of ciprofloxacin into aqueous humour. Trans Ophthalmol Soc UK 1986; IO5:650-652. 4. Dunphy EB. Ocular complications ofcerebrospinal meningitis. Arch Ophthalmol 1936; I5: 118-124 . 5. Krause AC, Rosenberg W. Treatment of metastatic meningococcic endophthalmitis: report of a case. Arch Ophthalmol 1944; 32: lO9-112. 6. Hedges TR, McAllister R, Coriell LL, Moore W. Metastatic endophthalmitis as a complication of meningococcic meningitis. Arch Ophthalmol 1956; 55: 503-505. 7. Mahdi G, Tutton M, Evans-Jones G. Ophthalmitis in meningococcal disease. Arch Dis Child 1988; 63:550-551 • 8. Lazar NK. Early ocular complications of epidemic meningitis. Arch Ophthalmol 1936; 15: 118--124 .

9- Lewis PW. Ocular complications of meningococcic meningitis: observations in 35o cases. Am ff Ophthalmol 194o; 23: 617-632. IO. Brisner JH, Hess JB. Meningococcal endophthalmitis without meningitis. Can ff Ophthalmol I 9 8 I ; I 6 : I O 0 - I O I . II. Auerbach SB, Leach CT, Bateman BJ, Sidikaro Y, Cherry JD. Meningococcal endophthalmitis without concomitant septicaemia or meningitis. Pediatr Infect Dis J 1989; 8 : 4I 1-413 .

Endophthalmitis caused by Neisseria meningitidis.

Letters to the E d i t o r 299 2. Dissaix E, Maggiore G, De Giacomo C, Mondell M, Martes P. Alvatez F. Autoimmune hepatitis in children and hepatiti...
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