Case Presentation: A 20 year-old IVDU female presented with 3 days of left eye pain and redness to an urgent ophthalmologist visit. She was found to have left eye retinal whitening superior to the macula to which vitreous tap was performed. Patient started on empiric treatment with injection of vancomycin, ceftriaxone, and voriconazole. Vitreous fluid Periodic Acid-Schiff (PAS) and gram stain were negative and patient was admitted to the hospital for endogenous endophthalmitis work-up. The patient’s social history is significant for living in a wooded area in upstate New York, IV-drug use and unprotected sexual intercourse with a new partner. Physical examination revealed a diffusely erythematous left eye. Empiric antibiotic with Bactrim was started to cover for Toxoplasmosis since patient had cat exposure. Initial labs including CMP, CBC with differential and lactic acid were within normal limits. Blood cultures, HIV, RPR, Burgdorferi IgG, CMV IgG/IgM, CMV/HSV PCR were negative. However, Burgdorferi IgM was 3/3 bands positive and patient diagnosed with lyme endophthalmitis. Ophthalmology and Infectious Disease consult teams recommended Ceftriaxone for 2 weeks and outpatient follow up with both specialist. Unfortunately, 4 weeks after admission patient lost vision of the left eye.
Discussion: Our patient presented with a uniocular uveitis due to lyme disease which progressed to endophthalmitis and ultimate destruction of uniocular vision. Ocular Lyme borreliosis probably still remains an underdiagnosed disorder, partly because of difficulties in the serodiagnosis, and because the clinical ocular features are not specific and can sometimes be vague. Often in healthy young patient with no other medical problems, these symptoms can be attributed to more common conjunctivitis or uveitis and the diagnosis of lyme disease can be delayed and detrimental to the patient. Photophobia and severe periodic ocular pain can be characteristic symptoms. Ocular manifestations have been reported to occur in different stages of Lyme borreliosis in early stages, within a few weeks to a few months of infection, and, in the late stage, several months to years after the infection incident.
Conclusions: This is a case of a 20 year-old woman who developed unilateral endophthalmitis leading to blindness during the course of this disease. Endophthalmitis should be high in the differential diagnosis because it can lead to not only visual loss, but also increased risk of mortality. Ocular and systemic symptoms of endophthalmitis are usually nonspecific, and early diagnosis and treatment are important to prevent blindness. Physicians treating patients from lyme disease endemic areas need to be aware of the protean clinical manifestation. Systemic findings, meticulous exclusion of other infectious and detailed medical history are essential.