Journal of the Royal Society of Medicine Volume 83 May 1990
Meningococcal endophthalmitis and pericarditis
H L C Beynon MRcP Department of Rheumatology, Hammersmith Hospital, Du Cane Road, London W12 OHS S Hague FRCS Moorfields Eye Hospital, London Keywords: meningococcus; endophthalmitis; pericarditis
With the recent increase in the incidence of acute meningococcal meningitis we report two rare features of meningococcal infection, primary meningococcal pericarditis followed by bilateral endophthalmitis. The patient did not have overt meningitis or septicaemia. Recognition of the more unusual organ-specific manifestations of meningococcal infection may prevent serious morbidity. Case report A 58-year-old West Indian woman was admitted with acute pericarditis, she was pyrexial 380C and an electrocardiogram showed concave ST segment elevation tbiroughout the lateral leads. Forty-eight hours later she complained of a painful left eye. On examination, the left eye was red with a hazy cornea and visual acuity had fallen to counting fingers at one metre. Apart from a central lens opacity the right eye was normal, there were no neurological signs and no evidence of cardiac tamponade. Investigations at this stage showed a white blood count of 10.5 x 109/1 (85% neutrophils), an erythrocyte sedimentation rate of 95 mm, in the first hour, negative autoantibody profile, normal serum complement profile and a chest X-ray showed a globular heart shadow. Four days after admission one blood culture grew Neisseria meningitidis group C type 2b. Treatment with intravenous benzylpenicillin 2 MU four hourly was commenced and continued for 14 days along with mydriatics and topical steroids to the left eye. General clinical improvement was rapid but her left visual acuity steadily deteriorated during the first 7 days ofthe illness to appreciation of light and dark only. On day nine, over a 12-h period right-sided vision fell to counting fingers at one metre. Further ophthalmological assessment showed that, the right anterior chamber was quiet, there were cortical lens opacities and the intraocular pressure was 10 mmHg. An inferior retinal detachment was diagnosed on ultrasound which was responsible for the acute drop in visual acuity of the right eye. The left eye was inflamed with a punctate corneal epitheliopathy and a cyclitic membrane. There was no fimdal view but ultrasound showed no retinal detachment. A right vitreolensectomy was performed. A vitreous Gram stain was negative and no organisms were cultured. The retinal detachment was repaired with an improvement in
An unusual cause of femoral vein obstruction
I Hudson FRCS G J Sadow FRCS Department of Orthopaedic Surgery, Kingston Hospital, Kingston-upon-Thames, Surrey Keywords: osteochondroma; femoral vein; venous obstruction; venography
Osteochondromas (osteocartilagenous exostoes) are common tumours which occasionally cause local pressure on vessels
331
corrected visual acuity to 6/60. The prognosis for vision in the left eye was felt not to justify proceeding to aurgery. In other respects the patient made a good recovery, and there were no cardiac sequelae. Discussion The usual clinical presentation of Neisseria meningitidis is acute meningococcaemia with meningitis. But the dominant clinical form is only a part of the complete disease. Meningococcal pericarditis may be classified into three groups (1) primary meningococcal pericarditis, where the initial and predominant clinical finding is pericarditis; (2) pericarditis complicating an acute meningococcaemia; and (3) aseptic pericarditis which is believed to be immunoloically mediated. The prognosis of primary meningococcal pericarditis is good though pericardiocentesis is often required'. Ophthalmic manifestations of meningococcal infection are rare. Beeson and Westerman2 in a review of 3575 cases, documented 18 cases of eye involvement. Meningococcal eye infections can be classified into three groups: (a) those occurring without meningitis, the majority being primary conjunctival infections; (b) where meningitis follows the conjunctivitis; and (c) secondary eye infections which occur during or after an attack of meningocccal meningitis, the meningococcus reaching the eye via blood stream tastatic spead3. Endophthalmitis is an unusual sequel of meningococcal infection, though until 1975 Neiseeria meningitidis was the commonest cause of metastatic endophthalmitis4. Seven out of eight cases of meningococcal endophthalmitis reviewed by Grunwald et ad recovered completely in response to prompt treatment with intravenous benzyl penicillin. In the single case which resulted in blindness the classical symptoms and signs of meningococcal infection were absent which led to a delay in the initiation of appropriate treatment.; We report this case in order to emphasize the need for recognition of two of the more unusual features of meningococcal infection, which can occur in the absence ofthe classical symptoms and signs Qf meningococcal disease. Acknowledgment: We thank Dr R Blackwood and Dr M Walport for allowing us to report this case. References 1 Hardy DJ, Bartholomew WR, Amsterdam D. Pathophysiology of primary meningococcal pericarditis associated with Neisseria meningitidis group C. Diagn Microbiol Infect Dis 1986,4:259-65 2 Beeson PB, Westerman E. Cerebrospinal fever-analysis of 3575 case reports, with special reference to sulphonamide therapy. Br Med J 1943;1:497-500 3 Shuttleworth FN, Benstead JG. Primary meningococcal ophthalmia. Br Med J 1947;2:568-9 4 Shammas HF. Endogenous E Coli endophthalmitis. Surv Ophthalmol 1977;429-35 5 Grunwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis: a contemporary reappraisal. Surv Ophthalmol 1986;31:281-101
(Accepted 29 March 1989)
0141-0768/90/
050331-01/$02.00/0 © 1990 The Royal Society of Medicine
and nerves (frequently around the knee) and very rarely undergo malignant change. A case is presented of one such lesion arising from the pelvis obstructing the femoral vein. Management of this extremely unusual cause of unilateral lower limb oedema was facilitated by venography. Case report A 20-year-old woman presented with a 5-year history of a slowly enlarging lump in the right groin, recently causing discomfort when walking. In the 5 or 6 weeks preceding presentation the right thigh had swelled slightly. On examination there was a 2 x 3 cm hard mass situated below and lateral to the pubic tubercle. There were prominent superficial veins over the anterior aspect of the right thigh which was 4 cm larger in circumference than the
0141-0768/90/ 050331-02/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 May 1990
332
*. ....
11b_~~~~~~~~~~~~~~~~R- 11111 a_
Figure 1. Plain X-ray showing an osteochondroma arising from right superior pubic ramus
left. Calf circumference was increased by 2 cm. The clinical diagnosis was femoral vein obstruction due to a pelvic exostosis. Plan radiographs show an osteochondroma arising from the superior pubic ramus (Figure 1) and a venogram (Figure 2) shows severe narrowing of the femoral vein as it passes around the lateral border of the tumour. At operation, the tumour mass was found to arise from the superior pubic ramus by a short, broad stalk, it was covered by an incomplete cartilage cap. Excision was complete. Histological examination of the specimen confirmed it to be an osteocartilagenous exostosis or osteochondroma. There was no evidence of malignancy. Postoperative recovery was uncomplicated and the limb swelling resolved over the following 6 months. Discussion Osteochondromas of the pelvis are frequently deeply situated, remain asymptomatic and are therefore incidental findings. Those in more superficial sites present as painless bony lumps. Tumours may exist singly or as multiple osteochondromatosis (diaphyseal aclasia), which has an autosomal dominant pattern of inheritance. Malignant degeneration, which is said to occur in five to ten per cent of multiple osteochondromata, is rare in solitary lesions though increases with proximity to the axial skeleton and is most likely to involve the flat bones of the pelvis and scapula. The -most widely reported vascular complication is development of a false aneurysm of the popliteal artery caused by damage to the vessel wall from abrasion on an osteochondroma of the distal femur'. Compression of the popliteal vein is also recognized2 and in a recently reported case3 thrombosis of the popliteal vein occurred following compression between an exostosis and a pseudo-aneurysm of the adjacent artery. Obstruction of the femoral vein by a pelvic osteochondroma has not previously been reported. The diagnosis was made clinically and confirmed by venography. Pelvic osteochondromas should be removed because of the threat of malignant degeneration; and resection should include the base of the stalk. Venography in this case was useful as it confirmed that the lesion was responsible for the limb oedema and delineated the anatomy ofthe tumour preoperatively making surgical excision easier and safer. References 1 Shah PJR. Aneurysm of the popliteal artery secondary to trauma from an osteochondroma of the femur: A case report and review of the literature. Br J Surg 1978;65:786-8 2 Scarborough J, Porter JM, Beals RK, Antonvic R, Keller FS. Stenosis ofthe popliteal vein caused by an osteochondroma ofthe distal femur. Diagnostic Imaging 1979;48:167-70 3 Lizoma VA, Zerbini MA, Gagliardi RA, Howell L. Popliteal vein thrombosis and popliteal artery pseudo-aneurysm complicating osteochondroma of the femur. Am J Radiol 1987;148:783-4
Figure 2. Venogram showing obstruction of the femoral vein by the tumour
Perforating eye injuries caused by dog bites
N P Jones FRCS FCOphth Manchester Royal Eye Hospital, Manchester M13 9WH Keywor&k dog bites; perforating eye injury; prevention
Severe dog bite lacerations of the head and face are uncommon, but often involve special problems of tissue loss and wound infection'-3. The most common facial sites
(Accepted 2 May 1989. Correspondence to Mr I Hudson, Department of Orthopaedic Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF)
affected are lips, nose and cheek'. The ocular adnexae may be affected, but perforating ocular injury is rare. The course oftwo such cases is reported, with comment on the need for prevention of such injuries.
Case reports Case 1: An 11-year-old girl was attacked by a Dobermann Pinscher. The dog had been purchased the day before by a childminder, left in charge ofthe patient. The girl attempted to stroke the animal and was bitten about the face and scalp. On presentation there were complex full-thickness scalp lacerations on the left side with extensive exposure of the calva, and a deep laceration of the left cheek. A large
0141-0768/90/ 050332-02/$02.00/0 © 1990 The Royal Society of Medicine
Meningococcal endophthalmitis and pericarditis
H L C Beynon MRcP Department of Rheumatology, Hammersmith Hospital, Du Cane Road, London W12 OHS S Hague FRCS Moorfields Eye Hospital, London Keywords: meningococcus; endophthalmitis; pericarditis
With the recent increase in the incidence of acute meningococcal meningitis we report two rare features of meningococcal infection, primary meningococcal pericarditis followed by bilateral endophthalmitis. The patient did not have overt meningitis or septicaemia. Recognition of the more unusual organ-specific manifestations of meningococcal infection may prevent serious morbidity. Case report A 58-year-old West Indian woman was admitted with acute pericarditis, she was pyrexial 380C and an electrocardiogram showed concave ST segment elevation tbiroughout the lateral leads. Forty-eight hours later she complained of a painful left eye. On examination, the left eye was red with a hazy cornea and visual acuity had fallen to counting fingers at one metre. Apart from a central lens opacity the right eye was normal, there were no neurological signs and no evidence of cardiac tamponade. Investigations at this stage showed a white blood count of 10.5 x 109/1 (85% neutrophils), an erythrocyte sedimentation rate of 95 mm, in the first hour, negative autoantibody profile, normal serum complement profile and a chest X-ray showed a globular heart shadow. Four days after admission one blood culture grew Neisseria meningitidis group C type 2b. Treatment with intravenous benzylpenicillin 2 MU four hourly was commenced and continued for 14 days along with mydriatics and topical steroids to the left eye. General clinical improvement was rapid but her left visual acuity steadily deteriorated during the first 7 days ofthe illness to appreciation of light and dark only. On day nine, over a 12-h period right-sided vision fell to counting fingers at one metre. Further ophthalmological assessment showed that, the right anterior chamber was quiet, there were cortical lens opacities and the intraocular pressure was 10 mmHg. An inferior retinal detachment was diagnosed on ultrasound which was responsible for the acute drop in visual acuity of the right eye. The left eye was inflamed with a punctate corneal epitheliopathy and a cyclitic membrane. There was no fimdal view but ultrasound showed no retinal detachment. A right vitreolensectomy was performed. A vitreous Gram stain was negative and no organisms were cultured. The retinal detachment was repaired with an improvement in
An unusual cause of femoral vein obstruction
I Hudson FRCS G J Sadow FRCS Department of Orthopaedic Surgery, Kingston Hospital, Kingston-upon-Thames, Surrey Keywords: osteochondroma; femoral vein; venous obstruction; venography
Osteochondromas (osteocartilagenous exostoes) are common tumours which occasionally cause local pressure on vessels
331
corrected visual acuity to 6/60. The prognosis for vision in the left eye was felt not to justify proceeding to aurgery. In other respects the patient made a good recovery, and there were no cardiac sequelae. Discussion The usual clinical presentation of Neisseria meningitidis is acute meningococcaemia with meningitis. But the dominant clinical form is only a part of the complete disease. Meningococcal pericarditis may be classified into three groups (1) primary meningococcal pericarditis, where the initial and predominant clinical finding is pericarditis; (2) pericarditis complicating an acute meningococcaemia; and (3) aseptic pericarditis which is believed to be immunoloically mediated. The prognosis of primary meningococcal pericarditis is good though pericardiocentesis is often required'. Ophthalmic manifestations of meningococcal infection are rare. Beeson and Westerman2 in a review of 3575 cases, documented 18 cases of eye involvement. Meningococcal eye infections can be classified into three groups: (a) those occurring without meningitis, the majority being primary conjunctival infections; (b) where meningitis follows the conjunctivitis; and (c) secondary eye infections which occur during or after an attack of meningocccal meningitis, the meningococcus reaching the eye via blood stream tastatic spead3. Endophthalmitis is an unusual sequel of meningococcal infection, though until 1975 Neiseeria meningitidis was the commonest cause of metastatic endophthalmitis4. Seven out of eight cases of meningococcal endophthalmitis reviewed by Grunwald et ad recovered completely in response to prompt treatment with intravenous benzyl penicillin. In the single case which resulted in blindness the classical symptoms and signs of meningococcal infection were absent which led to a delay in the initiation of appropriate treatment.; We report this case in order to emphasize the need for recognition of two of the more unusual features of meningococcal infection, which can occur in the absence ofthe classical symptoms and signs Qf meningococcal disease. Acknowledgment: We thank Dr R Blackwood and Dr M Walport for allowing us to report this case. References 1 Hardy DJ, Bartholomew WR, Amsterdam D. Pathophysiology of primary meningococcal pericarditis associated with Neisseria meningitidis group C. Diagn Microbiol Infect Dis 1986,4:259-65 2 Beeson PB, Westerman E. Cerebrospinal fever-analysis of 3575 case reports, with special reference to sulphonamide therapy. Br Med J 1943;1:497-500 3 Shuttleworth FN, Benstead JG. Primary meningococcal ophthalmia. Br Med J 1947;2:568-9 4 Shammas HF. Endogenous E Coli endophthalmitis. Surv Ophthalmol 1977;429-35 5 Grunwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis: a contemporary reappraisal. Surv Ophthalmol 1986;31:281-101
(Accepted 29 March 1989)
0141-0768/90/
050331-01/$02.00/0 © 1990 The Royal Society of Medicine
and nerves (frequently around the knee) and very rarely undergo malignant change. A case is presented of one such lesion arising from the pelvis obstructing the femoral vein. Management of this extremely unusual cause of unilateral lower limb oedema was facilitated by venography. Case report A 20-year-old woman presented with a 5-year history of a slowly enlarging lump in the right groin, recently causing discomfort when walking. In the 5 or 6 weeks preceding presentation the right thigh had swelled slightly. On examination there was a 2 x 3 cm hard mass situated below and lateral to the pubic tubercle. There were prominent superficial veins over the anterior aspect of the right thigh which was 4 cm larger in circumference than the
0141-0768/90/ 050331-02/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 May 1990
332
*. ....
11b_~~~~~~~~~~~~~~~~R- 11111 a_
Figure 1. Plain X-ray showing an osteochondroma arising from right superior pubic ramus
left. Calf circumference was increased by 2 cm. The clinical diagnosis was femoral vein obstruction due to a pelvic exostosis. Plan radiographs show an osteochondroma arising from the superior pubic ramus (Figure 1) and a venogram (Figure 2) shows severe narrowing of the femoral vein as it passes around the lateral border of the tumour. At operation, the tumour mass was found to arise from the superior pubic ramus by a short, broad stalk, it was covered by an incomplete cartilage cap. Excision was complete. Histological examination of the specimen confirmed it to be an osteocartilagenous exostosis or osteochondroma. There was no evidence of malignancy. Postoperative recovery was uncomplicated and the limb swelling resolved over the following 6 months. Discussion Osteochondromas of the pelvis are frequently deeply situated, remain asymptomatic and are therefore incidental findings. Those in more superficial sites present as painless bony lumps. Tumours may exist singly or as multiple osteochondromatosis (diaphyseal aclasia), which has an autosomal dominant pattern of inheritance. Malignant degeneration, which is said to occur in five to ten per cent of multiple osteochondromata, is rare in solitary lesions though increases with proximity to the axial skeleton and is most likely to involve the flat bones of the pelvis and scapula. The -most widely reported vascular complication is development of a false aneurysm of the popliteal artery caused by damage to the vessel wall from abrasion on an osteochondroma of the distal femur'. Compression of the popliteal vein is also recognized2 and in a recently reported case3 thrombosis of the popliteal vein occurred following compression between an exostosis and a pseudo-aneurysm of the adjacent artery. Obstruction of the femoral vein by a pelvic osteochondroma has not previously been reported. The diagnosis was made clinically and confirmed by venography. Pelvic osteochondromas should be removed because of the threat of malignant degeneration; and resection should include the base of the stalk. Venography in this case was useful as it confirmed that the lesion was responsible for the limb oedema and delineated the anatomy ofthe tumour preoperatively making surgical excision easier and safer. References 1 Shah PJR. Aneurysm of the popliteal artery secondary to trauma from an osteochondroma of the femur: A case report and review of the literature. Br J Surg 1978;65:786-8 2 Scarborough J, Porter JM, Beals RK, Antonvic R, Keller FS. Stenosis ofthe popliteal vein caused by an osteochondroma ofthe distal femur. Diagnostic Imaging 1979;48:167-70 3 Lizoma VA, Zerbini MA, Gagliardi RA, Howell L. Popliteal vein thrombosis and popliteal artery pseudo-aneurysm complicating osteochondroma of the femur. Am J Radiol 1987;148:783-4
Figure 2. Venogram showing obstruction of the femoral vein by the tumour
Perforating eye injuries caused by dog bites
N P Jones FRCS FCOphth Manchester Royal Eye Hospital, Manchester M13 9WH Keywor&k dog bites; perforating eye injury; prevention
Severe dog bite lacerations of the head and face are uncommon, but often involve special problems of tissue loss and wound infection'-3. The most common facial sites
(Accepted 2 May 1989. Correspondence to Mr I Hudson, Department of Orthopaedic Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF)
affected are lips, nose and cheek'. The ocular adnexae may be affected, but perforating ocular injury is rare. The course oftwo such cases is reported, with comment on the need for prevention of such injuries.
Case reports Case 1: An 11-year-old girl was attacked by a Dobermann Pinscher. The dog had been purchased the day before by a childminder, left in charge ofthe patient. The girl attempted to stroke the animal and was bitten about the face and scalp. On presentation there were complex full-thickness scalp lacerations on the left side with extensive exposure of the calva, and a deep laceration of the left cheek. A large
0141-0768/90/ 050332-02/$02.00/0 © 1990 The Royal Society of Medicine
