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Show Journal of Neuro- Ophthalmology 16( 4): 291- 294, 1996. © 1996 Lippincott- Raven Publishers, Philadelphia Infective Endocarditis- A Photo Essay Jaya Varadarajan, M. D., and Eric R. Eggenberger, D. O. Infective endocarditis is a microbial affliction of the heart valves or endocardium. Subacute bacterial endocarditis ( SBE) may result from infection with low- virulence organisms such as Streptococcus viridans and Staphylococcus epidermidis, or partially treated infection. We report a case of SBE with neuro- ophthalmologic manifestations. Key Words: Infective endocarditis- Roth spot. CASE REPORT A 37- year- old white male developed headaches and partial complex seizures. Seizures were controlled with Tegretol, and T2- weighted magnetic resonance images of the brain demonstrated three high signal lesions without enhancement following gadolinium ( Fig. 1). Lumbar puncture revealed protein of 58 mg/ dl, glucose of 57 mg/ dl, with 500 RBCs and 30 WBCs ( 95% mononuclear), and negative cultures. Transthoracic echocardiogram and contrast angiogram of the brain were normal. From the Unit for Neuro- Visual Disorders, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, U. S. A. Address correspondence and reprint requests to Dr. E. Eggenberger, A 217 Clinical Center, Michigan State University, East Lansing, MI 48824. FIG. 1. High- signal lesions on T2 weighted magnetic resonance imaging. 292 292 /. VARADARAJAN AND E. R. EGGENBERGER FIG. 2. Goldmann perimetry demonstrates a left homonymous visual field defect with additional defects OS at presentation ( A), with subsequent improvement ( B- D). INFECTIVE ENDOCARDITIS 293 FIG. 3. Roth spots at initial presentation ( A) that ultimately resolved with antibiotic treatment ( B- D). FIG. 4. T r a n s t h o r a c ic echocardiogram demonstrating the valvular vegetation ( arrow). 294 /. VARADARAJAN AND E. R. EGGENBERGER A month later he noted " spots" in the central visual field OU. Goldmann perimetry revealed a small left homonymous scotoma and several additional scotomas ( Fig. 2a), while ophthalmoscopy demonstrated Roth spots ( Fig. 3a). Laboratory testing revealed erythrocyte sedimentation rate 70 mm/ h, WBC 9.9/ mm3, and hemoglobin of 11.5 g/ dl. Repeat transthoracic echocardiogram revealed valvular vegetation ( Fig. 4) and Streptococcus mutatis was cultured from the blood. Following a 6- week course of intravenous penicillin, improved visual fields ( Figs. 2b- d) and retinal findings ( Figs. 3b- d) were documented. DISCUSSION Clear- centered retinal hemorrhages in SBE were first described by Moritz Roth in 1872 ( 1). Although Roth spots are primarily associated with SBE and leukemia, they have also been documented with conditions resulting in increased venous pressure ( mothers or neonates following complicated labor or delivery, battered children, difficult intubation, AVM with hemorrhage), ischemia ( high- altitude anoxia, carbon monoxide poisoning, profound anemia), increased capillary fragility ( hypertension or diabetic retinopathy, phlebitis), oral contraceptive intake, viral pneumonia, and kala azar ( 2- 4). The white center in these hemorrhages usually consists of a fibrin plug that forms as a result of platelet adhesion following capillary wall rupture with extrusion of blood into the nerve fiber layer ( 2,5). In leukemia, the white center may consist of leukemic cells ( 6). Neurologic involvement occurs in 29% of SBE and may result from cerebral ischemia, mycotic aneurysm, headaches, seizures, toxic encephalopathy, or meningitis ( 7). A high index of suspicion is often required to make the diagnosis of SBE. Transesophageal echocardiography has improved detection of valvular vegetations and may be useful when transthoracic echocardiography is normal ( 8). REFERENCES 1. Roth M. Uber netzhautaffecstionen bei wundfiebrin. Dtsch A Chir 1872; 1: 471- 84. 2. Duane TD, Osher RH, Green WR. White centered hemorrhages: their significance. Ophthalmology 1980; 87: 66- 9. 3. Vouters MJ. Les endothelites retiniennes. Arch Ophthalmol 1958; 18: 262. 4. Tassman WF, O'Brien, Hahn K. Retinal lesions in Kala azar. Am } Ophthalmol 1960; 50: 161. 5. Von Barsewisch B. " Perinatal retinal hemorrhages. New York: Springer- Verlag, 1979: 48, 51- 2. 6. Green WR. Retina. In: Spencer WH, ed. Ophthalmic pathology, an atlas and textbook. Vol 2. Philadelphia: WB Saunders, 1985: 662- 8, 1058- 64. 7. Jones HR Jr, Seikert RG, Geraci JE. Neurologic manifestations of bacterial endocarditis. Ann Intern Med 1969; 71: 21- 7. 8. Saner H, Lange HW, Olson J. Significance of transesophageal echocardiography as an adjunct to transthoracic echocardiography. Schweiz Med Wochenschr 1990; 129( 45): 1701- 3. / Neuw- Ophthalmol, Vol. 16, No. 4, 1996 |
