History
A 36-year-old white female presented for a consult following admission to a nearby hospital for drug-dependency. The neurology team had interpreted some brain abnormalities when reviewing her magnetic resonance imaging (MRI) scans and asked us to rule out the possibility of retinal embolic disease.

While she exhibited signs of confusion and psychiatric distress, she had no visual complaints. Additionally, her ocular history was unremarkable for evidence of trauma or surgery. Her systemic history was significant for substance abuse (cocaine and heroin), but otherwise unremarkable. She denied using any prescribed medications and reported no known allergies.

Diagnostic Data
Her uncorrected visual acuity measured 20/30 O.U. at distance and near. Upon the use of -1.00D sphere in both eyes, her visual acuity improved to 20/20 O.U. Her pupils were equal, round and reactive to light, with no afferent defect. Extraocular muscle movements were full O.U.

Confrontation fields uncovered a right homonymous inferior quadrantanopia that was consistent with the brain injury seen on MRI testing.

Slit lamp examination revealed normal anterior segment structures and chambers. Her intraocular pressure measured 18mm Hg O.U. The significant fundus finding in her left eye is illustrated in the photograph.

Your Diagnosis
How would you approach this case? Does this patient require any additional tests? What is your diagnosis? How would you manage this patient? What’s the likely prognosis?

A fundus image of our patient’s left eye. What do you notice?

Discussion
Additional diagnostic examinations included automated visual fields, brightness testing and color testing (with specific attention to ruling out red desaturation). We photodocumented her posterior poles.

The diagnosis in this case was systemic vasculopathy with Roth-type hemorrhage (Roth spot). This finding confirmed retinal micro-embolic disease, which was most likely secondary to infectious bacterial endocardidtis. The consult was returned to the neurology department.

Roth spots are defined as white-centered intraretinal hemorrhages. They are most frequently associated with leukemia, septic choreoretinitis secondary to bacterial endocarditis, and the vascular changes seen within capillaries in patients with diabetes.^1,2 Other, less common associations include anemia, sickle cell disease, lupus and collagen vascular disease.¹

Endocarditis is defined by a proliferative and exudative inflammation of the pericardium surrounding the heart.3 It is characterized by the presence of vegetative deposits on the surface of the endocardium, within the endocardium or involving a heart valve.3 It may also afflict the inner aspects of the cardiac chambers.3

Endocarditis may occur as a primary idiopathic disease or in association with another concurrent disease.³ It is a common complication in Staphylococcus aureus bacteremia (SAB).⁴ In a study that compared the risk factors, clinical manifestations and outcome in a prospective cohort of 430 patients with S. aureus endocarditis, it was found that the condition was significantly more common in drug users (46%) than non-users (14%).⁴ Additionally, drug users tended to be notably younger, had fewer fatal underlying diseases or predisposing heart diseases, and their endocarditis was more commonly community-acquired.⁴

The yearly incidence of infectious endocarditis is estimated at seven cases per 100,000 in the U.S., and this number continues to increase.⁵ The prognosis for the entity itself is influenced by timely diagnosis and adequate therapy.⁵ Antimicrobial therapy should be established only after quantitative sensitivity tests.⁵

Unfortunately, bacterial endocarditis has the capability of affecting other organs. The prognosis of collateral, associated diseases depends upon the speed in which they are identified, the availability of treatment to that tissue and, in many cases, the diagnosis of the underlying cause (unfortunately, the signs and symptoms of the affected organ that experiences the associated disease often leads to the initial discovery of the endocarditis). Therefore, preventative measures that protect the system are often not issued until some morbidity has been established.

1. Jarger EA, Jeffers JB, Tipperman R. Differential diagnosis of ocular signs. In: Rhee DJ, Pyfer MF. The Wills Eye Manual. Philadelphia: Lippincott, Williams and Wilkins; 1999:7-17.  
2. Mandic BD, Potocnjak V, Bencic G, et al. Visual loss as initial presentation of chronic myelogenous leukemia. Coll Antropol. 2005;29(Suppl 1):141-3.
3. Friel JP. Endocarditis. In: Friel JP. Dorland’s Illustrated Medical Dictionary 26th ed. Philadelphia: WB Saunders Co.; 1985:440.
4. Ruotsalainen E, Sammalkorpi K, Laine J, et al. Clinical manifestations and outcome in Staphylococcus aureus endocarditis among injection drug users and nonaddicts: a prospective study of 74 patients. BMC Infect Dis. 2006;6(9):137.
5. Horstkotte D, Piper C. New aspects of infective endocarditis. Minerva Cardioangiol. 2004;52(4):273-86.