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• The association of endogenous endophthalmitis and infective endocarditis also deserves mention
  oscar,m jolobe
  Published on: 9 August 2023

• Published on: 9 August 2023

  The association of endogenous endophthalmitis and infective endocarditis also deserves mention

  • oscar,m jolobe, retired geriatrician British Medical Association

  Over and above the scenario cited by the authors, where the presence of Roth spots became a "red flag" for infective endocarditis(IE)[1], clinicians also need to take note of endogenous endophthalmitis as a "red flag" for IE, both in the context of native valve IE, and in the context of intracardiac device-related IE.
  Endophthalmitis and native valve infective endocarditis:-
  Awareness of endophthalmitis as a manifestation of IE is of heightened value when IE presents in the absence of a cardiac murmur, so-called "silent" infective endocarditis. In one patient with silent IE , Roth spots were identified in the same eye that was affected by endogenous endophthalmitis[2]. In another patient with silent IE initial transthoracic echocardiography(TTE) did not disclose any vegetations. Ten days later, however, transoesophageal echocardiography(TOE) disclosed the presence of vegetations[3]. The clinical course of another patient with silent IE was characterised by non diagnostic initial TTE, and nondiagnostic TOE on day 12. On day 31, however, TOE showed severe aortic regurgitation and what appeared to be a vegetation on the aortic valve. Intraoperatively, however, what had previously appeared to be a vegetation proved to be a destroyed non coronary valve tip[4].
  Endophthalmitis and infective endocarditis attributable to intracardiac devices:-

  Endogenous endophthalmitis is also a red flag for infective endocarditis attr...

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  Over and above the scenario cited by the authors, where the presence of Roth spots became a "red flag" for infective endocarditis(IE)[1], clinicians also need to take note of endogenous endophthalmitis as a "red flag" for IE, both in the context of native valve IE, and in the context of intracardiac device-related IE.
  Endophthalmitis and native valve infective endocarditis:-
  Awareness of endophthalmitis as a manifestation of IE is of heightened value when IE presents in the absence of a cardiac murmur, so-called "silent" infective endocarditis. In one patient with silent IE , Roth spots were identified in the same eye that was affected by endogenous endophthalmitis[2]. In another patient with silent IE initial transthoracic echocardiography(TTE) did not disclose any vegetations. Ten days later, however, transoesophageal echocardiography(TOE) disclosed the presence of vegetations[3]. The clinical course of another patient with silent IE was characterised by non diagnostic initial TTE, and nondiagnostic TOE on day 12. On day 31, however, TOE showed severe aortic regurgitation and what appeared to be a vegetation on the aortic valve. Intraoperatively, however, what had previously appeared to be a vegetation proved to be a destroyed non coronary valve tip[4].
  Endophthalmitis and infective endocarditis attributable to intracardiac devices:-

  Endogenous endophthalmitis is also a red flag for infective endocarditis attributable to intracardiac devices such as permanent pacemekers and implantable cardioverter defibrillators. The diagnosis of device-related IE comes to mind most readily when the patient has concurrent inflammatory signs of of infection of the device pocket[5]. Regardless of presence or absence of signs of device pocket infection , however, the presence of endogenous endophthalmitis should, also, raise the index of suspicion for device -related IE, especially when stigmata of septic pulmonary embolism are also present[6]. In the latter example, where no mention was made of the appearance of the device pocket, TOE showed a 20 mm mobile vegetation attached to the right atrial lead[6]. The association of endophthalmitis, pulmonary consolidation(with or without cavitation) , and hypotension(the latter attributable to systemic sepsis), is a "triad" that should raise the index of suspicion for device-related IE[7].
  Echocardiography expedites the workup of suspected intracardiac device-related IE. TOE has greater sensitivity than TTE for identifying vegetations on the leads and for identifying vegetations on the heart valves. Accordingly, TOE can be offered as the first echocardiographic test if clinical suspicion is sufficiently high[8]. Nuclear imaging, using 18 Fluoro Deoxy Glucose positron emission tomography computed tomography is highly specific for lead endocarditis given the fact that, unlike TOE, it can also distinguish between infected thrombi and uninfected thrombi attached to the leads[8]. Sensitivity is however, suboptimal, given the the negative results believed to be attributable to previous antibiotic therapy or attributable to vegetation size being lower than the spatial resolution of nuclear imaging[9].
  A comprehensive account of best practice in the work up of suspected device-related IE was made by Dilsizian et al[8].
  I have no conflict of interest.
  References
  [1]Ng JY., Zarook E., Nicholson L et al
  Eyes and the heart: what a clinician should know
  Heart 2023
  Epub ahead of print
  DOI 10.1136/heartjnl-2022-322081
  [2]Carmelli G., Surles T., Brown A
  Endophthalmitis and myocotic aneurysm: The only clues to underlying endocarditis
  Clin Pract Cases Emerg Med 2018
  https://doi.org/10.5811/cpcem.2017.8.34723
  [3]Sim YR., Lee YJ., Park SW et al
  Infective endocarditis presenting as endogenous endophthalmitis secondary to streptococcus agalactiae in a healthy adult
  CSE Rep Literat Rev Infect Chemother 2017;49:286-292
  [4]Nakata M., Mashidori T., Higa N et al
  Infective endocarditis with no underlying disease for which bacterial endophthalmitis have been first symptom
  Intern Med 2020;59:2061-2065
  [5]Looser PM., Saleh L., Thomas G., Cheung JW
  Systemic infection due to subcutaneous implantable cardioverter defibrillator implantation: Importance of early recognition and treatment of device pocket related complications
  Heart Rhythm Case Reports 2017;3:40-42
  [6] Patel N., McDonald ML., Bradford NS et al
  AngioVac debulking in endocarditis patients with large, device-related vegetations
  The Journal of Innovations in Cardiac Rhythm Management 2018;9:3291-3296
  [7]Sarvat B., Sarria JC
  Implantable cardioverter-defibrillator infection due to Scetosporium apiospermum
  Journal of Infection 2007;55:e109-e113
  [8]Dilsizian V., Budde RPJ., Chen W et al
  Best practice for imaging cardiac device-related infections and endocarditis
  A JACC Cardiovascular imaging expert panel statement
  JACC Cardiovascular Imaging 2022;15:891-911
  [9]Cautela J., Alessandrini S., Carmmiller S et al
  Diagnostic yield of FDG positron emission tomography/computed tomography in patients with CEID infection: a pilot study
  Europace 2013;15:252-257

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  Conflict of Interest:
  None declared.

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