Case 15 - Retina and vascular pathology

Bilateral Vision Blurring with Fever in a Child

12-year-old girl - Fever + generalized weakness - Sudden bilateral vision blur - White-centered retinal hemorrhages

Illustrated eye for pathology case review

Case 15Roth Spots / Bacterial Endocarditis

Clinical Presentation

A 12-year-old girl enters the hospital for evaluation of fever and generalized weakness. She states her vision suddenly became blurred this week. Both eyes have similar findings.

Learner Questions

Describe the ophthalmoscopic findings.
What are the histopathologic correlates of these findings?
What questions should be asked in the review of systems? What physical findings would you look for?
What is the most likely diagnosis?

Answer Framework

Findings

ROTH SPOTS - flame/boat-shaped intraretinal hemorrhages with WHITE or PALE CENTERS (fibrin-platelet thrombus from septic embolus + leukocytic infiltrate). Distributed around the posterior pole and disc. Disc edema may be present. Minimal vitreous reaction.

ROS + exam

ROS: congenital heart disease, prior dental work/infections, joint pain, SOB. Physical (Duke Criteria): new/changed cardiac murmur, Osler nodes (tender finger/toe nodules - immune complex), Janeway lesions (non-tender palmar/plantar macules - septic emboli), splinter hemorrhages, petechiae, splenomegaly.

Histopathology

Septic microemboli lodge in retinal capillaries -> fibrin-platelet thrombus + inflammatory response -> capillary wall disruption -> surrounding hemorrhage. White center = fibrin thrombus + lymphocytes/macrophages. Risk of endophthalmitis if emboli seed the vitreous cavity.

Diagnosis

Infective Endocarditis (SBE) on congenital heart disease - Strep viridans most common at this age. Workup: Blood cultures x 3 (separate sites BEFORE antibiotics - most important test), TTE/TEE echocardiography (vegetations = major Duke criterion), CBC, ESR/CRP, urinalysis (microscopic hematuria from immune complex glomerulonephritis).

Teaching Pearl

Roth spots = white-centered retinal hemorrhages = intraretinal septic emboli -> demand blood cultures and echocardiography in any febrile patient. In a child, suspect underlying congenital heart disease. The peripheral stigmata of IE (Janeway, Osler, splinter hemorrhages, Roth spots) all represent the same pathophysiology: sustained bacteremia -> septic emboli + immune complex deposition.

Original answer transcript

Findings ROS + exam
ROTH SPOTS - flame/boat-shaped intraretinal hemorrhages with WHITE or PALE CENTERS ROS: congenital heart disease, prior dental work/infections, joint pain, SOB. Physical (Duke
(fibrin-platelet thrombus from septic embolus + leukocytic infiltrate). Distributed around Criteria): new/changed cardiac murmur, Osler nodes (tender finger/toe nodules - immune
the posterior pole and disc. Disc edema may be present. Minimal vitreous reaction. complex), Janeway lesions (non-tender palmar/plantar macules - septic emboli), splinter
hemorrhages, petechiae, splenomegaly.
Histopathology Diagnosis
Septic microemboli lodge in retinal capillaries -> fibrin-platelet thrombus + inflammatory Infective Endocarditis (SBE) on congenital heart disease - Strep viridans most common at
response -> capillary wall disruption -> surrounding hemorrhage. White center = fibrin this age. Workup: Blood cultures x 3 (separate sites BEFORE antibiotics - most important
thrombus + lymphocytes/macrophages. Risk of endophthalmitis if emboli seed the vitreous test), TTE/TEE echocardiography (vegetations = major Duke criterion), CBC, ESR/CRP,
cavity. urinalysis (microscopic hematuria from immune complex glomerulonephritis).
TEACHING PEARL
Roth spots = white-centered retinal hemorrhages = intraretinal septic emboli -> demand blood cultures and echocardiography in any febrile patient. In a child, suspect
underlying congenital heart disease. The peripheral stigmata of IE (Janeway, Osler, splinter hemorrhages, Roth spots) all represent the same pathophysiology: sustained
bacteremia -> septic emboli + immune complex deposition.