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