1137
NOTES
Ocular Manifestations of Mycoplasma pneumoniae Infection Mark B. Salzman, Sunil K. Sood, Michael L. Slavin, and Lorry G. Rubin
From the Division of Infectious Diseases, Department of Pediatrics, Schneider Children's Hospital of Long Island Jewish Medical Center, and the Division of Neuro-ophthalmology, Department of Ophthalmology, Long Island Jewish Medical Center, The Long Island Campus for the Albert Einstein College of Medicine, New Hyde Park, New York
Patients who have infection due to Mycoplasma pneumoniae most often present with pneumonia or pharyngitis [1, 2]. However, protean manifestations of infection with this organism that involve many organ systems can occur [1, 2]. We describe a 15-year-old boy who had iritis and optic disk edema associated with M. pneumoniae infection and review the world literature on the ocular manifestations associated with infection with this pathogen. A 15-year-old boy was well until 6 days before admission to the hospital when he developed tactile fever, vomiting, diarfhea, abdominal pain, neck stiffness, and headache. Four days later, a nonpruritic erythematous rash appeared on his chest, back, and legs that was accompanied by bilateral conjunctival injection. On physical examination he was alert and oriented. He was afebrile but had orthostatic hypotension. Visual acuity was normal. Conjunctival and perilimbal injection was present, and iritis was noted bilaterally on slitlamp examination. Each optic disk was hyperemic and swollen with elevation at the nasal optic disk border. The macula and retina on each side were normal, as were the pharynx and ears; the patient's neck was mildly stiff upon flexion. Erythematous circular target lesions on the chest and back were noted. The remainder of the findings of the physical examination were unremarkable. Results of laboratory tests at the time of admission revealed a normal white blood cell count and an erythrocyte sedimentation rate of 73 mm/h. Results of analysis of the CSF were normal. The closing pres-
Received 18 October 1991; revised 30 December 1991. Reprints or correspondence: Dr. Lorry G. Rubin, Division of Infectious Diseases, Schneider Children's Hospital of Long Island Jewish Medical Center, New Hyde Park, New York 11042. Clinical Infectious Diseases 1992;14:1137-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0017$02.00
sure at lumbar puncture was 200 mm H 2 O (an opening pressure was not obtained). The patient developed a fever (temperature, 102°F) in the hospital and was discharged after 1 day of rehydration and observation. No antibiotics were administered. Bacterial cultures of the CSF, blood, urine, and stool were negative, as were viral cultures of swab specimens from the throat and rectum. The cell lines used for isolation of virus included rhesus monkey kidney, human lung carcinoma, embryonic human lung, and rabbit kidney. In addition, the hemadsorption test with use of 0.5% guinea pig red blood cells was performed on the rhesus monkey kidney cell monolayer at 7 days. Serological studies for detection of Lyme disease and Epstein-Barr virus were also negative. A titer of antibody to M. pneumoniae by immunofluorescence was 1:8 at admission and ^_1:256 14 days later; the IgM antibody titer was 1:80. Ten days after he was discharged, the patient developed transient arthritis of the first metatarsal-phalangeal joint of his right foot. By this time his other symptoms had completely resolved, although bilateral optic disk edema and iritis were still present, both of which resolved 4 weeks later. Optic disk swelling and iritis are unusual manifestations of M. pneumoniae infection. Our patient presented with gastroenteritis followed by erythema multiforme, iritis, optic disk edema, and subsequently arthritis. The absence of pneumonia or other respiratory symptoms was unusual but has been reported in 21% of cases of patients with neurological complications secondary to M. pneumoniae infection [2]. Conjunctivitis appears to be the most frequent ocular manifestation of M. pneumoniae infection [2]. However, uveitis has not been reported as a complication of this infection. The diagnosis of iritis for our patient was made by slitlamp examination performed as part of an ophthalmologic consultation. Nonspecific presumedly viral illnesses, occurring as community epidemics, have been followed by iritis or
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
Ocular manifestations of Mycoplasma pneumoniae infection, other than conjunctivitis, are uncommon. Optic disk swelling, optic nerve atrophy, retinal exudates and hemorrhages, and cranial nerve palsies have been infrequently reported. We describe a 15-year-old patient who developed bilateral optic disk edema and iritis during an acute infection with M. pneumoniae and review the world literature on findings associated with ocular manifestations of infection with this pathogen. Although our patient experienced complete resolution of iritis and optic disk edema after 6 weeks, several patients described in the literature have experienced permanent sequelae as a result of optic neuropathy.
1138
Salzman et al.
CID 1992;14 (May)
Table 1. Summary of data on M. pneumoniae infection and optic disk swelling. Age (y)/ sex
Visual acuity
Other findings
Outcome
[3] [4]
10/F 59/M
Normal Impaired
Optic disk edema resolved in 7 w Complete recovery after 1 y
[5]
11/M
NA
[6]
25/M
Impaired
[ 7]*
8/M
Aseptic meningitis Aseptic meningitis, right hemiparesis, nonfluent aphasia Aseptic meningitis, Guillain-Barre syndrome, peripapillary flameshaped hemorrhages Aseptic meningitis; bilateral, horizontal, and vertical nystagmus; altered mental status; right 7th nerve weakness Guillain-Barre syndrome, seizure, coma, bilateral 6th nerve palsy
[Reference]
[8]
33/M
Impaired
Central scotomata
[9]
47/M
Impaired
[10]
8/M
Impaired
Blindness (right eye before left eye), polyneuritis (sensory nerves affected more than motor nerves) Bilateral retinal hemorrhages and exudates
[10]
9/M
Impaired
Bilateral retinal hemorrhages and exudates
[10]
NA/M
Impaired
Macular hemorrhage, large central scotomata
1 1]
32/M
Impaired
[12]
8/F
Impaired
Right amaurosis fugax lasting several minutes Blindness, retroorbital pain, perimacular hemorrhages
[PR]
15/M
[
Normal
Bilateral iritis
Optic disk edema resolved with mannitol, residual distal muscle weakness 9 mo later Visual acuity normal after 2 mo but impaired color perception 9 mo later Optic disk edema resolved in 20 d, visual acuity normal after 12 w Optic disk edema resolved over 4 mo, macular exudates resolved after 1 y Optic disk edema resolved over 2 mo, visual acuity of left eye impaired 1 y later Optic disk edema resolved in 2 mo, visual acuity normal after 8 mo Visual acuity normal after 11 mo Left optic disk edema resolved over 6 w, permanent optic nerve atrophy of the right eye Optic disk edema and iritis resolved over 6 w
NOTE. NA = not available; and PR = present report. * This patient had papilledema due to increased intracranial pressure.
iridocyclitis. Therefore, although iritis has not been a previously documented manifestation of M. pneumoniae infection, it is possible that some episodes labeled as postviral iritis were actually associated with M. pneumoniae infection. In addition, the diagnosis of uveitis can be overlooked because a slit-lamp examination is not performed for all cases of eye redness associated with M. pneumoniae infection. Optic disk edema associated with M. pneumoniae infection has been infrequently described in the world literature (table 1) [3-12]. For our patient, it is unclear if the optic disk edema represented papilledema caused by increased intracranial pressure or local papillitis without signs of optic neuropathy. Since several of the patients whose cases were reported had optic disk edema with normal CSF pressure [5, 6, 9], a process unrelated to increased intracranial pressure is the most likely explanation.
Third and sixth nerve palsies [5-7], homonymous hemianopia [13], and vertical and horizontal nystagmus [4, 6] have also been reported in association with M. pneumoniae infection, although these findings, when present, have accompanied other significant neurological findings. Because the ocular manifestations of M. pneumoniae infection normally occur several days to weeks after the initial symptoms [1-14], they are probably not due to direct invasion. A variety of mechanisms have been suggested as explanations for postinfectious complications of M. pneumoniae infection [1, 2]; these include generation of cross-reacting antibodies, immune complexes, toxin production, microthrombosis, impaired immunity, and direct invasion. Although direct invasion is unlikely, M. pneumoniae has on occasion been isolated from the CSF [14]. In summary, M. pneumoniae has been associated with a
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
NA
Optic disk edema improved over 10 w, muscle weakness improved over 7 mo Mild horizontal nystagmus persisted after 2 mo
CID 1992;14 (May)
Ocular Findings with M. pneumoniae Infection
variety of ocular findings. Except for conjunctivitis, ocular manifestations appear to be rare. Ocular findings usually accompany other neurological findings; thus, the case presented herein is especially unusual. Since M. pneumoniae is a common pathogen occurring in children and young adults, it should be considered in the differential diagnosis of any febrile illness that is accompanied by uveitis, optic disk edema, or any of the other ocular signs described herein, even in the absence of respiratory symptoms or other neurological findings.
1. Cherry JD. Mycoplasma and ureaplasma infections. In: Feigin RD, Cherry JD, eds. Textbook of pediatric infectious diseases. Vol 2. Philadelphia: WB Saunders, 1981:1450-75. 2. Levine DP, Lerner AM. The clinical spectrum of Mycoplasma pneumoniae infections. Med Clin North Am 1978;62:961-78. 3. Novelli VM, Marshall WC. Optic disc swelling and Mycoplasma pneumoniae [letter]. Pediatr Infect Dis J 1984;3:597. 4. Behan PO, Feldman RG, Segerra JM, Draper IT. Neurological aspects of mycoplasmal infection. Acta Neurol Scand 1986;74:314-22. 5. Steele JC, Gladstone RM, Thanasophon S, Fleming PC. Mycoplasma pneumoniae as a determinant of the Guillain-Barre syndrome. Lancet 1969;2:710-4.
6. Murray HW, Masur H, Senterfit LB, Roberts RB. The protean manifestations of Mycoplasma pneumoniae infection in adults. Am J Med 1975;58:229-42. 7. Lerer RJ, Kalaysky SM. Central nervous system disease associated with Mycoplasma pneumoniae infection: report of five cases and review of the literature. Pediatrics 1973;52:658-68. 8. Filtenborg JA, Degn T. Mycoplasma pneumoniae infektion kompliceret med neuritis retrobulbaris. Ugeskr Laeger 1982;144:2234-5. 9. Yamamoto T, Inoue N, Yamashita Y, Shiraishi S, Murai Y. A case of bilateral optic neuritis and polyneuritis associated with Mycoplasma pneumoniae infection [in Japanese]. Rinsho Shinkeigaku 1983;23: 404-9. 10. Verin P, Vildy A, Cales R, Bapt JB. Une nouvelle etiologie de l'oedeme des voies optiques pregeniculees: le Mycoplasma pneumoniae. Bull Soc Ophtalmol Fr 1980;80:1009-12. 11. Michel D, Laurent B, Granouillet R, Gaudin-Terrasse OD. Infections aigues, recentes, et parfois persistantes a Mycoplasma pneumoniae, associees a des manifestations neurologiques: discussion des liens de causalite. Rev Neurol (Paris) 1981;137:393-413. 12. Carriere JP, Didier J, Icart J, Dalous A. Mycoplasma pneumoniae et pathologie infectieuse du systeme nerveux. Pediatrie 1975;30:45— 53. 13. Taylor MJ, Burrow GN, Strauch B, Horstmann DM. Meningoencephalitis associated with pneumonitis due to Mycoplasma pneumoniae. JAMA 1967;199:813-6. 14. Bayer AS, Galpin JE, Theofilopoulos AN, Guze LB. Neurologic disease associated with Mycoplasma pneumoniae pneumonitis. Ann Intern Med 1981;94:15-20.
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
References
1139
NOTES
Ocular Manifestations of Mycoplasma pneumoniae Infection Mark B. Salzman, Sunil K. Sood, Michael L. Slavin, and Lorry G. Rubin
From the Division of Infectious Diseases, Department of Pediatrics, Schneider Children's Hospital of Long Island Jewish Medical Center, and the Division of Neuro-ophthalmology, Department of Ophthalmology, Long Island Jewish Medical Center, The Long Island Campus for the Albert Einstein College of Medicine, New Hyde Park, New York
Patients who have infection due to Mycoplasma pneumoniae most often present with pneumonia or pharyngitis [1, 2]. However, protean manifestations of infection with this organism that involve many organ systems can occur [1, 2]. We describe a 15-year-old boy who had iritis and optic disk edema associated with M. pneumoniae infection and review the world literature on the ocular manifestations associated with infection with this pathogen. A 15-year-old boy was well until 6 days before admission to the hospital when he developed tactile fever, vomiting, diarfhea, abdominal pain, neck stiffness, and headache. Four days later, a nonpruritic erythematous rash appeared on his chest, back, and legs that was accompanied by bilateral conjunctival injection. On physical examination he was alert and oriented. He was afebrile but had orthostatic hypotension. Visual acuity was normal. Conjunctival and perilimbal injection was present, and iritis was noted bilaterally on slitlamp examination. Each optic disk was hyperemic and swollen with elevation at the nasal optic disk border. The macula and retina on each side were normal, as were the pharynx and ears; the patient's neck was mildly stiff upon flexion. Erythematous circular target lesions on the chest and back were noted. The remainder of the findings of the physical examination were unremarkable. Results of laboratory tests at the time of admission revealed a normal white blood cell count and an erythrocyte sedimentation rate of 73 mm/h. Results of analysis of the CSF were normal. The closing pres-
Received 18 October 1991; revised 30 December 1991. Reprints or correspondence: Dr. Lorry G. Rubin, Division of Infectious Diseases, Schneider Children's Hospital of Long Island Jewish Medical Center, New Hyde Park, New York 11042. Clinical Infectious Diseases 1992;14:1137-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0017$02.00
sure at lumbar puncture was 200 mm H 2 O (an opening pressure was not obtained). The patient developed a fever (temperature, 102°F) in the hospital and was discharged after 1 day of rehydration and observation. No antibiotics were administered. Bacterial cultures of the CSF, blood, urine, and stool were negative, as were viral cultures of swab specimens from the throat and rectum. The cell lines used for isolation of virus included rhesus monkey kidney, human lung carcinoma, embryonic human lung, and rabbit kidney. In addition, the hemadsorption test with use of 0.5% guinea pig red blood cells was performed on the rhesus monkey kidney cell monolayer at 7 days. Serological studies for detection of Lyme disease and Epstein-Barr virus were also negative. A titer of antibody to M. pneumoniae by immunofluorescence was 1:8 at admission and ^_1:256 14 days later; the IgM antibody titer was 1:80. Ten days after he was discharged, the patient developed transient arthritis of the first metatarsal-phalangeal joint of his right foot. By this time his other symptoms had completely resolved, although bilateral optic disk edema and iritis were still present, both of which resolved 4 weeks later. Optic disk swelling and iritis are unusual manifestations of M. pneumoniae infection. Our patient presented with gastroenteritis followed by erythema multiforme, iritis, optic disk edema, and subsequently arthritis. The absence of pneumonia or other respiratory symptoms was unusual but has been reported in 21% of cases of patients with neurological complications secondary to M. pneumoniae infection [2]. Conjunctivitis appears to be the most frequent ocular manifestation of M. pneumoniae infection [2]. However, uveitis has not been reported as a complication of this infection. The diagnosis of iritis for our patient was made by slitlamp examination performed as part of an ophthalmologic consultation. Nonspecific presumedly viral illnesses, occurring as community epidemics, have been followed by iritis or
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
Ocular manifestations of Mycoplasma pneumoniae infection, other than conjunctivitis, are uncommon. Optic disk swelling, optic nerve atrophy, retinal exudates and hemorrhages, and cranial nerve palsies have been infrequently reported. We describe a 15-year-old patient who developed bilateral optic disk edema and iritis during an acute infection with M. pneumoniae and review the world literature on findings associated with ocular manifestations of infection with this pathogen. Although our patient experienced complete resolution of iritis and optic disk edema after 6 weeks, several patients described in the literature have experienced permanent sequelae as a result of optic neuropathy.
1138
Salzman et al.
CID 1992;14 (May)
Table 1. Summary of data on M. pneumoniae infection and optic disk swelling. Age (y)/ sex
Visual acuity
Other findings
Outcome
[3] [4]
10/F 59/M
Normal Impaired
Optic disk edema resolved in 7 w Complete recovery after 1 y
[5]
11/M
NA
[6]
25/M
Impaired
[ 7]*
8/M
Aseptic meningitis Aseptic meningitis, right hemiparesis, nonfluent aphasia Aseptic meningitis, Guillain-Barre syndrome, peripapillary flameshaped hemorrhages Aseptic meningitis; bilateral, horizontal, and vertical nystagmus; altered mental status; right 7th nerve weakness Guillain-Barre syndrome, seizure, coma, bilateral 6th nerve palsy
[Reference]
[8]
33/M
Impaired
Central scotomata
[9]
47/M
Impaired
[10]
8/M
Impaired
Blindness (right eye before left eye), polyneuritis (sensory nerves affected more than motor nerves) Bilateral retinal hemorrhages and exudates
[10]
9/M
Impaired
Bilateral retinal hemorrhages and exudates
[10]
NA/M
Impaired
Macular hemorrhage, large central scotomata
1 1]
32/M
Impaired
[12]
8/F
Impaired
Right amaurosis fugax lasting several minutes Blindness, retroorbital pain, perimacular hemorrhages
[PR]
15/M
[
Normal
Bilateral iritis
Optic disk edema resolved with mannitol, residual distal muscle weakness 9 mo later Visual acuity normal after 2 mo but impaired color perception 9 mo later Optic disk edema resolved in 20 d, visual acuity normal after 12 w Optic disk edema resolved over 4 mo, macular exudates resolved after 1 y Optic disk edema resolved over 2 mo, visual acuity of left eye impaired 1 y later Optic disk edema resolved in 2 mo, visual acuity normal after 8 mo Visual acuity normal after 11 mo Left optic disk edema resolved over 6 w, permanent optic nerve atrophy of the right eye Optic disk edema and iritis resolved over 6 w
NOTE. NA = not available; and PR = present report. * This patient had papilledema due to increased intracranial pressure.
iridocyclitis. Therefore, although iritis has not been a previously documented manifestation of M. pneumoniae infection, it is possible that some episodes labeled as postviral iritis were actually associated with M. pneumoniae infection. In addition, the diagnosis of uveitis can be overlooked because a slit-lamp examination is not performed for all cases of eye redness associated with M. pneumoniae infection. Optic disk edema associated with M. pneumoniae infection has been infrequently described in the world literature (table 1) [3-12]. For our patient, it is unclear if the optic disk edema represented papilledema caused by increased intracranial pressure or local papillitis without signs of optic neuropathy. Since several of the patients whose cases were reported had optic disk edema with normal CSF pressure [5, 6, 9], a process unrelated to increased intracranial pressure is the most likely explanation.
Third and sixth nerve palsies [5-7], homonymous hemianopia [13], and vertical and horizontal nystagmus [4, 6] have also been reported in association with M. pneumoniae infection, although these findings, when present, have accompanied other significant neurological findings. Because the ocular manifestations of M. pneumoniae infection normally occur several days to weeks after the initial symptoms [1-14], they are probably not due to direct invasion. A variety of mechanisms have been suggested as explanations for postinfectious complications of M. pneumoniae infection [1, 2]; these include generation of cross-reacting antibodies, immune complexes, toxin production, microthrombosis, impaired immunity, and direct invasion. Although direct invasion is unlikely, M. pneumoniae has on occasion been isolated from the CSF [14]. In summary, M. pneumoniae has been associated with a
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
NA
Optic disk edema improved over 10 w, muscle weakness improved over 7 mo Mild horizontal nystagmus persisted after 2 mo
CID 1992;14 (May)
Ocular Findings with M. pneumoniae Infection
variety of ocular findings. Except for conjunctivitis, ocular manifestations appear to be rare. Ocular findings usually accompany other neurological findings; thus, the case presented herein is especially unusual. Since M. pneumoniae is a common pathogen occurring in children and young adults, it should be considered in the differential diagnosis of any febrile illness that is accompanied by uveitis, optic disk edema, or any of the other ocular signs described herein, even in the absence of respiratory symptoms or other neurological findings.
1. Cherry JD. Mycoplasma and ureaplasma infections. In: Feigin RD, Cherry JD, eds. Textbook of pediatric infectious diseases. Vol 2. Philadelphia: WB Saunders, 1981:1450-75. 2. Levine DP, Lerner AM. The clinical spectrum of Mycoplasma pneumoniae infections. Med Clin North Am 1978;62:961-78. 3. Novelli VM, Marshall WC. Optic disc swelling and Mycoplasma pneumoniae [letter]. Pediatr Infect Dis J 1984;3:597. 4. Behan PO, Feldman RG, Segerra JM, Draper IT. Neurological aspects of mycoplasmal infection. Acta Neurol Scand 1986;74:314-22. 5. Steele JC, Gladstone RM, Thanasophon S, Fleming PC. Mycoplasma pneumoniae as a determinant of the Guillain-Barre syndrome. Lancet 1969;2:710-4.
6. Murray HW, Masur H, Senterfit LB, Roberts RB. The protean manifestations of Mycoplasma pneumoniae infection in adults. Am J Med 1975;58:229-42. 7. Lerer RJ, Kalaysky SM. Central nervous system disease associated with Mycoplasma pneumoniae infection: report of five cases and review of the literature. Pediatrics 1973;52:658-68. 8. Filtenborg JA, Degn T. Mycoplasma pneumoniae infektion kompliceret med neuritis retrobulbaris. Ugeskr Laeger 1982;144:2234-5. 9. Yamamoto T, Inoue N, Yamashita Y, Shiraishi S, Murai Y. A case of bilateral optic neuritis and polyneuritis associated with Mycoplasma pneumoniae infection [in Japanese]. Rinsho Shinkeigaku 1983;23: 404-9. 10. Verin P, Vildy A, Cales R, Bapt JB. Une nouvelle etiologie de l'oedeme des voies optiques pregeniculees: le Mycoplasma pneumoniae. Bull Soc Ophtalmol Fr 1980;80:1009-12. 11. Michel D, Laurent B, Granouillet R, Gaudin-Terrasse OD. Infections aigues, recentes, et parfois persistantes a Mycoplasma pneumoniae, associees a des manifestations neurologiques: discussion des liens de causalite. Rev Neurol (Paris) 1981;137:393-413. 12. Carriere JP, Didier J, Icart J, Dalous A. Mycoplasma pneumoniae et pathologie infectieuse du systeme nerveux. Pediatrie 1975;30:45— 53. 13. Taylor MJ, Burrow GN, Strauch B, Horstmann DM. Meningoencephalitis associated with pneumonitis due to Mycoplasma pneumoniae. JAMA 1967;199:813-6. 14. Bayer AS, Galpin JE, Theofilopoulos AN, Guze LB. Neurologic disease associated with Mycoplasma pneumoniae pneumonitis. Ann Intern Med 1981;94:15-20.
Downloaded from http://cid.oxfordjournals.org/ at University of Toronto Library on December 2, 2015
References
1139
