The eyes as a window to the heart: a case of infective endocarditis presenting with endophthalmitis

SESSION TITLE: Critical Care Case Report Posters 42 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Endogenous bacterial endophthalmitis (EBE) is a rare but severe ophthalmic emergency, which typically occurs from bacterial seeding of the eye from bacteremia (3). We present a case of a 60-year-old Caucasian male with recurrent hospitalizations for dizziness and hypotension with nondiagnostic workup including normal transthoracic echocardiogram, over the course of multiple admissions. He was eventually found to have EBE traced to methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus faecalis bacteremia from infective endocarditis. CASE PRESENTATION: A 60-year-old Caucasian male with alcohol dependence, hypertension, and type 2 diabetes mellitus presented to the emergency department (ED) after an episode of lightheadedness and syncope. He was found to have mild orthostatic hypotension; thus his antihypertensives were held. He had an otherwise unremarkable physical exam. Labs were unremarkable. Computed tomography of head was unremarkable. Orthostatic hypotension did not resolve with fluid administration and nonpharmacological therapies; thus further workup was initiated. Transthoracic echocardiogram (TTE) revealed no abnormalities. Carotid ultrasound showed bilateral grade 1 stenosis. He was discharged on hospital day six with midodrine 2.5 mg twice daily. One week later, patient returned to the ED with syncope and alcohol intoxication, complaining of malaise and unsteady gait. Urine alcohol level was 238 mg/dL and he had severe hypotension with standing blood pressure of 63/47. He was given intravenous fluids. Midodrine was increased to 5 mg three times daily. Hypotension resolved and he was discharged on hospital day five.One day after discharge, he returned to the ED with worsening lightheadedness, syncope, collapse, nausea, vomiting, and diarrhea. He was initially thought to have viral gastroenteritis. On hospital day 3, patient became hypoxic, tachycardic, severely hypotensive and developed sudden bilateral vision loss. He was intubated for acute hypoxic respiratory failure and transferred to intensive care unit where he was noted to have bilateral hypopyons and holosystolic heart murmur. Ophthalmology was consulted. Concern was raised for bacteremia and septic shock. Treatment was begun with bilateral intravitreal vancomycin injections; intravenous vancomycin, levofloxacin, ceftriaxone; and vasopressors. Trans-esophageal echocardiogram (TEE) was performed to search for infectious source and evaluate murmur. TEE revealed large vegetations on the posterior mitral valve leaflet and aortic valve. Blood cultures grew MRSA and Enterococcus faecalis. Despite aggressive therapy, patient developed multi-system organ failure and expired on hospital day 20. DISCUSSION: Bilateral endogenous endophthalmitis is a rare condition that can lead to complete loss of vision with bacteremia being a possible underlying cause. This condition may require intravitreal antimicrobial therapy or vitreoretinal surgery (2). Therefore, aggressive evaluation for potential sources of infection should be undertaken. The most common sites of infection are liver, lung, endocardium, urinary tract and meninges (3). Risk factors include diabetes, IV drug use and malignancy (3). In this case, ophthalmologic findings were a key driver in aggressive evaluation and treatment for infective endocarditis. CONCLUSIONS: TEE has a much better diagnostic accuracy for infective endocarditis than TTE and should thus be considered early in workup of patient with hypotension and signs of bacteremia (1). Ophthalmologic exam may play a key role in determining workup for patients with suspected bacteremia. REFERENCE #1: Bai AD, Steinberg M, Showler A, Burry L, Bhatia RS, Tomlinson GA, Bell CM, Morris AM. Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis. J Am Soc Echocardiogr. 2017 Jul;30(7):639-646.e8. doi: 10.1016/j.echo.2017.03.007. Epub 2017 May 5. PMID: 28483353. REFERENCE #2: Christensen SR, Hansen AB, La Cour M, Fledelius HC. Bilateral endogenous bacterial endophthalmitis: a report of four cases. Acta Ophthalmol Scand. 2004 Jun;82(3 Pt 1):306-10. doi: 10.1111/j.1600-0420.2004.00236.x. PMID: 15115453. REFERENCE #3: Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342 cases of endogenous bacterial endophthalmitis. Surv Ophthalmol. 2014 Nov-Dec;59(6):627-35. doi: 10.1016/j.survophthal.2014.06.002. Epub 2014 Jun 18. PMID: 25113611. DISCLOSURES: No disclosure on file for Rose Atris No relevant relationships by Michael Broadwell No relevant relationships by Fulton DeFour No disclosure on file for Wendell Erdman No relevant relationships by Ekemini Hogan No relevant relationships by Gogo-ogute Ibodeng No relevant relationships by UNWAM JUMBO No relevant relationships by William Kutsche No relevant relationships by Charles Mansour No relevant relationships by Juwairiah Mohammad No relevant relationships by Alixandra Ryan No relevant relationships by Daren Scroggie No relevant relationships by Nitesh Shrestha No relevant relationships by Suzana Sogorovic No relevant relationships by Dhruv Vasant No relevant relationships by Michael Wilson