Rashmitha Dachepally
Cleveland Clinic Children's Hospital
Cleveland, Ohio
Disclosure information not submitted.
Samir Latifi, MD
PHYSICIAN
Cleveland Clinic Children's Hospital, United States
Disclosure information not submitted.
Hemant Agarwal, MBBS, MD
PHYSICIAN
Cleveland Clinic Children's Hospital, United States
Disclosure information not submitted.
Title: Acute Bilateral Painless Vision Loss in a Pediatric Patient With Infective Endocarditis
Case Report Body:
Introduction: Five percent of patients with infective endocarditis (IE) present with ocular symptoms. We report acute onset of bilateral visual loss in an IE patient secondary to central retinal arterial occlusion (CRAO) and posterior ischemic optic neuropathy (PION).
Description: An 18 year old male patient with h/o congenital heart disease s/p multiple cardiac surgeries and 2 previous episodes of IE was admitted to the PICU for cardiac surgery evaluation. His previous IE episode was 4 months ago whereby he developed Staphylococcus aureus IE of the aortic valve that was complicated by septic emboli of the left middle cerebral artery, mycotic aneurysm and rupture leading to hemorrhagic infarction, right sided hemiplegia that was treated with aneurysmal clipping, decompressive hemicraniectomy, tracheostomy and antibiotics. At admission, echocardiogram revealed left ventricle dilation, moderate aortic stenosis and severe aortic regurgitation with a mobile vegetation (18 mm x 6 mm) attached to the non-coronary cusp of the aortic valve. Neuroimaging including MRI and digital subtraction angiography revealed a partially thrombosed aneurysm arising from the left supraclinoid internal carotid artery (4.8 cm x 4.3 cm x 4.3 cm) with minimal filling of the left middle cerebral artery territory, lack of visualization of left ophthalmic artery and collateral supply to the globe via distal branches of internal maxillary and the middle meningeal arteries. 2 days into admission he developed sudden onset of bilateral visual loss following an anesthesia procedure for his neuroimaging study on the previous day. It was associated with fever, low blood pressure and positive blood cultures. Ophthalmic examination revealed retinal whitening encompassing the macula and white lesion within the artery in the optic disc area in the right eye suggestive of septic emboli causing CRAO. His left eye revealed absence of pupillary response to light, reverse afferent pupillary defect with normal fundoscopic eye exam suggestive of PION.
Discussion: Less than 1% of IE patients develop CRAO. Vegetation size > 10 mm in IE is a risk factor for embolization. Limited blood supply and period of hypo perfusion of the left eye led to nonarteritic PION in our patient. CRAO and PION, both manifest as acute, painless visual loss and have no specific treatment.