Clinical Practice and Cases in Emergency Medicine

Introduction: Bacterial meningitis affects about 1.2 million people worldwide each year. Streptococcus pneumoniae is responsible for the majority of cases of bacterial meningitis in the United States and Europe, with visual impairment seen in 6.3% of patients. The etiology of acute vision loss in the setting of bacterial meningitis remains wide-ranging, most often occurring in the setting of endogenous endophthalmitis, optic neuropathy, and cortical blindness. Retinal necrosis is rare, and typically associated with viral meningitis, but has not been reported in bacterial meningitis.

Case report: A 66-year-old man with headache, malaise, and intermittent blurry vision, initially diagnosed with viral upper respiratory infection and presumed trigeminal neuralgia, presented to the emergency department with altered mental status, meningismus, and progressive bilateral vision loss. He was diagnosed with bacterial meningitis, and subsequent cerebrospinal fluid and blood cultures were positive for S pneumoniae. Ophthalmologic evaluation demonstrated bilateral nonreactive pupils, retinal ischemia, optic nerve pallor, and retinal necrosis but no intraocular inflammation. Brain magnetic resonance imaging showed multifocal cortical ischemic infarcts thought to be of embolic source. His hospitalization was complicated by mitral valve regurgitation, endocarditis, and cardiac tamponade requiring extensive surgical repair.

Conclusion: This case represents a rare presentation of bilateral retinal ischemia and necrosis in the setting of S pneumoniae meningitis without evidence of endophthalmitis. Awareness of atypical ocular presentations and differential diagnoses is vital in providing early diagnosis, treatment and specialist involvement.