Mycoplasma Pneumoniae: Case 2

pected causative agents including Author Affiliations: Departments of ease from M pneumoniae has also miotic and nonmiotic antiglau- Ophthalmology (Ms Geneva and Drs been reported, with conjunctivitis coma drugs, mydriatics, preserva- Barker-Griffith and Weisenthal), Pa- being the most frequent finding.2 tives, antiviral compounds, sulfon- thology (Dr Barker-Griffith), and Less common ophthalmologic mani- amides, penicillin, hydrocortisone, Biochemistry and Molecular Biol- festations of M pneumoniae include epidermal growth factor, prostaglan- ogy (Ms Geneva), State University cranial neuropathies, optic papilli- dins, practolol, and thyroid hor- of New York, Upstate Medical Uni- tis, and anterior uveitis.2 We pre- mone, none of which have been used versity, Syracuse; and Wills Eye In- sent herein 1 case of bilateral optic by the 2 patients reported herein. In stitute, Thomas Jefferson Univer- papillitis and 2 cases of uveitis sec- most instances, the prolonged use of sity, Philadelphia, Pennsylvania (Drs ondary to M pneumoniae infection. a topical medication seems to in- Eagle and Stefanyszyn). duce conjunctival epidermidaliza- Correspondence: Dr Barker- Report of Cases. Case 1. A 20-year- tion, which may resolve over the Griffith, Departments of Ophthal- old man presented with a 1-month course of a few months, after the mology and Pathology, 766 Irving history of blurry vision. Prior to pre- drug is discontinued. Persistent or Ave, Weiskotten Hall, Room 2137A, sentation, he completed a 1-week recurrent inflammation of the con- State University of New York, Up- course of oral levofloxacin for com- junctivae, as was observed in case 1, state Medical University, Syracuse, munity-acquired pneumonia. His vi- can itself lead to epidermidaliza- NY 13210 (barkerga@upstate sual acuity was 20/25 in the right eye tion. It has been proposed that the .edu). and 20/30 in the left eye. The oph- mechanism probably involves a re- Conflict of Interest Disclosures: thalmologic findings were normal, gion-specific cellular immune re- None reported. except for bilateral optic disc edema sponse to the topical application, Funding/Support: This study was (Figure 1A and B). The results of rather than a drug mechanism– supported by unrestricted grants from neuroimaging using magnetic reso- specific reaction, because the com- Research to Prevent Blindness and by nance imaging and all the cerebro- pounds that are responsible vary the Lions District 20-Y1. spinal fluid parameters, including opening pressure level and cell widely in chemical structure and 1. Roelofs AJ, Thompson K, Gordon S, Rogers MJ. 3 therapeutic effect. Molecular mechanisms of action of bisphospho- counts, were normal. The results of Conjunctival epidermidaliza- nates: current status. Clin Cancer Res. 2006; a laboratory workup for Lyme dis- 12(20, pt 2):6222s-6230s. ease, syphilis, and Bartonella henselae tion has been associated with ocu- 2. Aurich-Barrera B, Wilton L, Harris S, Shakir SA. lar drying related to exposure, Ste- Ophthalmological events in patients receiving were negative. The results of a chest vens-Johnson syndrome, and risedronate: summary of information gained radiograph were normal, and the lev- through follow-up in a prescription-event moni- avitaminosis A with xerophthal- toring study in England. Drug Saf. 2006;29(2): els of angiotensin-converting en- mia.6 Because ocular drying was pre- 151-160. zyme and calcium were within nor- 3. Wright P. Squamous metaplasia or epidermal- mal limits. Because of his recent sent in case 2, it is a possible ization of the conjunctiva as an adverse reac- mechanism. tion to topical medication. Trans Ophthalmol Soc outpatient treatment for community- Based on the clinical and histo- UK. 1979;99(2):244-246. acquired pneumonia, serology test- 4. Fraunfelder FW, Fraunfelder FT. Bisphospho- ing for M pneumoniae was per- pathologic findings in these 2 unre- nates and ocular inflammation. N Engl J Med. lated patients, we propose that the 2003;348(12):1187-1188. formed, and elevated IgM and IgG administration of risedronate so- 5. Papapetrou PD. Bisphosphonate-associated ad- antibodies were found. The patient verse events. Hormones (Athens). 2009;8(2): dium is the primary cause of their 96-110. was treated with a 1-week course of conjunctival epidermidalization. 6. Maumenee AE. Keratinization of the conjuntivae. oral azithromycin. One month af- Although the mechanisms for the de- Trans Am Ophthalmol Soc. 1979;77:133-143. ter presentation, the patient’s vi- velopment of Actonel-induced epi- sual acuity returned to 20/20 in both dermidalization are not fully under- eyes, and his optic disc edema had stood, potential mechanisms include resolved. conjunctival inflammation and dry Mycoplasma pneumoniae: Case 2. A 14-year-old boy pre- eye. Conjunctival epidermidaliza- The Other Masquerader sented with a 1-month history of bi- tion constitutes a serious, vision- lateral eye pain, blurry vision, head- threatening condition that is likely Mycoplasma pneumoniae is a bacte- ache, and subjective fevers. On to resolve after discontinuation of the rium in the class of Mollicutes and physical examination, he was found drug, but it could lead to vision loss is a common cause of atypical pneu- to have an erythematous macular if the drug is continued. Therefore, monia, particularly in children and rash on his lower extremities. His vi- clinicians should be aware that con- young adults. A Mycoplasma infec- sual acuity was 20/40 and 20/50 in junctival epidermidalization is a po- tion primarily manifests as a respi- the right and left eyes, respectively. tentially dangerous adverse effect of ratory tract disease, but an extrapul- An ophthalmologic examination re- risedronate sodium. monary manifestation has occurred vealed bilateral conjunctival injec- in up to 25% of infected patients. The tion, with 3ϩ cell and flare in the an- Ivayla I. Geneva, BA organ systems that may be in- terior chambers. A dilated fundus Ralph C. Eagle Jr, MD volved include the skin, the gastro- examination showed 2ϩ cell in the Ann Barker-Griffith, MD, FRCSC intestinal tract, and the musculosk- vitreous and bilateral optic disc Mary Stefanyszyn, MD eletal, cardiac, renal, hematopoetic, edema and serous macular detach- Robert Weisenthal, MD and nervous systems.1 Ocular dis- ments (Figure 2A and B). There

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©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 within normal limits. The results of A B viral serologic testing for adenovi- rus, rhinovirus, influenza A and B vi- ruses, and respiratory syncytial vi- rus were also negative. The results of a magnetic resonance imaging/ magnetic resonance venography of the brain were within normal limits. A lumbar puncture revealed a normal opening pressure, normal chemistry results, a normal cell count, and a negative culture re- sult. Serology testing for M pneumo- Figure 1. Bilateral optic disc edema in a 20-year-old man who presented with a 1-month history of blurry vision (case 1; A [right eye] and B [left eye]). niae showed elevated IgM and IgG antibodies. Macular optical coherence tomography revealed peripap- A B illary and macular serous detachments (Figure 3), and fluorescein angiography revealed bilateral optic disc leakage without evidence of leakage in the macula (Figure 4A and B). In addition to topical steroids and cycloplegic eye drops, he was treated with a 1-week course of oral azithromycin. Because his optic disc edema and macular serous detachments persisted for 2 weeks after presentation, he was subse- Figure 2. Bilateral optic disc edema and macular detachments in a 14-year-old boy who presented with a quently treated with 40 mg of oral 1-month history of bilateral eye pain, blurry vision, headache, and subjective fevers (case 2; A [right eye] and B [left eye]). prednisone daily. One month after presentation, the uveitis and serous macular detachments resolved. A B Case 3. A 27-year-old woman presented with a 1-week history of bilateral eye pain, photophobia, injec- tions, and blurry vision. Her visual acuity was 20/100 with pinhole to 20/30 in both eyes. The results of an examination showed extreme pho- Figure 3. Optical coherence tomographic image showing bilateral peripapillary and macular serous tophobia, diffuse conjunctival in- detachments in a 14-year-old boy who presented with a 1-month history of bilateral eye pain, blurry ϩ vision, headache, and subjective fevers (case 2; A [right eye] and B [left eye]). jection, and 2 cell and flare in the anterior chamber. The results of a dilated fundus examination were A B within normal limits. The results of a full uveitis workup were negative, as in the 2 previous cases. Be- cause she presented within 1 month of the 2 previous patients, M pneumoniae serology testing was per- formed and revealed elevated IgG and IgM antibodies. The patient was treated with topical steroids and cycloplegic eye drops, in addition to a 1-week course of oral azithromycin. The uveitis resolved after 2 Figure 4. Fluorescein angiographic images showing bilateral optic disc leakage in a 14-year-old boy who weeks of treatment, and her visual presented with a 1-month history of bilateral eye pain, blurry vision, headache, and subjective fevers (case 2; A [right eye] and B [left eye]). acuity returned to baseline. was no macular star or exudate. The cytoplasmic antibody, HLA-B27, an- Comment. M pneumoniae is a com- results of a full uveitis workup were giotensin-converting enzyme, Lyme mon human pathogen responsible negative for antinuclear antibody, disease, syphilis, and B henselae. The for atypical cases of community- rheumatoid factor, antineutrophil erythrocyte sedimentation rate was acquired pneumonia, or “walking

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Patients Source Sex Age, y Ocular Findings Systemic Findings Outcome Salzman et al,2 1992 Male 15 Bilateral optic disc Gastroenteritis, fever, and erythema Optic disc edema and iritis resolved edema and iritis multiforme after 6 wk Dawidek et al,3 1991 Male 36 Bilateral iritis Fever, cough, and macular rash on Recurrence of iritis 1 mo after lower extremities presentation; resolution after 3mo Di Maria et al,4 1999 Male 38 Bilateral optic disc Fever, cough, headache, Iritis resolved after 2 mo edema and iritis erythematous rash, and pneumonia Yashar et al,5 2001 Female 15 Bilateral panuveitis, Meningitis, fever, vomiting, myalgia, Panuveitis and Roth spots resolved Roth spots, and dizziness, and pleuritic chest pain after 3 wk retinal hemorrhages Weinstein et al,6 2006 Female 5 Bilateral optic disc Fever, arthralgia, abdominal pain, Optic disc edema and iritis resolved edema and iritis and lethargy after 6 wk

pneumonia.” There is a higher There have been only 5 reported Providence, RI 02903 (robert prevalence of infection in children cases in the literature of anterior uve- [email protected]). and young adults (up to 40% in chil- itis secondary to M pneumoniae Conflict of Interest Disclosures: dren), and reports of outbreaks are (Table).2-6 In 3 of the 5 cases, con- None reported. common in closed populations such comitant findings of bilateral optic 1. Waites KB, Talkington DF. Mycoplasma pneu- as those of military recruits and col- disc edema and anterior uveitis were moniae and its role as a human pathogen. Clin lege students.1 All 3 patients in our reported, but those patients had nor- Microbiol Rev. 2004;17(4):697-728. series presented to our service within 2,4,6 2. Salzman MB, Sood SK, Slavin ML, Rubin LG. mal retinal findings. Case2inour Ocular manifestations of Mycoplasma pneumo- a 2-month period, and 2 of the pa- series is, to our knowledge, the first niae infection. Clin Infect Dis. 1992;14(5):1137- tients were college students. Al- case of uveitis from M pneumoniae 1139. 3. Dawidek GM. Anterior uveitis associated with though permanent vision loss from associated with bilateral macular and Mycoplasma pneumoniae pneumonia. Postgrad optic papillitis has been previously peripapillary serous detachments, Med J. 1991;67(786):380-382. reported, all 3 of our patients recov- 4. Di Maria A, Ruberto G, Redaelli C, Gualtieri G. but perhaps this is a more severe pre- Anterior uveitis associated with Mycoplasma ered their baseline visual acuity sentation along the same clinical pneumoniae pneumonia: a case report. Acta Oph- within 1 month of treatment. thalmol Scand. 1999;77(3):349-350. spectrum of inflammatory disease. 5. Yashar SS, Yashar B, Epstein E, Viani RM. Uve- M pneumoniae contains both Of our 3 patients, only the 20-year- itis associated with Mycoplasma pneumoniae glycolipid and protein antigens old man who presented with a meningitis. Acta Ophthalmol Scand. 2001;79 (1):100-101. that elicit antibody responses in 1-month history of blurry vision 1 6. Weinstein O, Shneck M, Levy J, Lifshitz T. infected individuals. Circulating (case 1) had pneumonia secondary Bilateral acute anterior uveitis as a presenting immune complexes have been symptom of Mycoplasma pneumoniae infection. to his infection, which underscores Can J Ophthalmol. 2006;41(5):594-595. found in the serum of patients with the fact that extrapulmonary in- M pneumoniae–associated pneumo- volvement can occur even in the ab- nia, and this type III hypersensitiv- sence of clinically overt respiratory Optic Nerve Involvement ity reaction is believed to cause tract disease. We hope that our case microvasculitis from immune com- From Pseudomonas series will help highlight this com- aeruginosa–Associated plexes depositing along vessel mon human pathogen as a cause of walls in the eye.2,3 Another mecha- Skull Base Osteomyelitis uveitis and papillitis, and we be- nism by which Mycoplasma infec- lieve that M pneumoniae should be tion is thought to cause uveitis is Skull base osteomyelitis (SBO) is an included in the differential diagno- through direct invasion of the bac- uncommon but life-threatening con- sis when a young and otherwise teria in the anterior chamber.3 The dition caused by invasive bacterial or healthy person presents with uve- most common method for diagnos- fungal infection.1 Diabetes mellitus, ing Mycoplasma infection is itis or optic disc edema preceded by chronic otitis externa, and immuno- through serology testing for IgM a febrile illness. suppression are frequently associ- and IgG antibodies. Direct poly- Enchun M. Liu, MD ated with SBO.1,2 More than 60% of merase chain reaction analysis is Robert H. Janigian Jr, MD patients with SBO are men, and Pseu- still not widely available, and a cul- domonas aeruginosa is the most com- ture of M pneumoniae takes up to Author Affiliations: Department of mon bacterial pathogen identified in several weeks. The enzyme-linked Ophthalmology, Brown Univer- SBO.1,2 Cranial nerve palsy most fre- immunosorbent assay test used at sity, Providence, Rhode Island. quently involves cranial nerve VII, our institution has a sensitivity and Correspondence: Dr Janigian, De- followed by the lower cranial nerves specificity of 94.5% and 87.5%, partment of Ophthalmology, Brown (IX-XI).1,2 We report 2 cases of SBO respectively. University, 1 Hoppin St, Ste 200, with rare unilateral optic nerve in-

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