To report a case of simultaneous bilateral choroidal neovascularization (CNV) associated with Staphylococcus aureus infective endocarditis.
A 35-year-old man presented with acute visual impairment 14 days after cardiac surgery for acute infective endocarditis caused by methicillin-susceptible S. aureus . Fundus photography, fluorescein angiography, optical coherence tomography (OCT), and OCT angiography confirmed the presence of a single CNV area in the right eye and three CNV areas in the left eye. Treatment with intravitreal aflibercept resulted in an improvement in the visual acuity in both eyes.
Conclusion and Importance
The findings from this case highlight the importance of monitoring visual symptoms in patients with infective endocarditis. CNV can result in vision loss when it involves the macula; therefore, prompt diagnosis is important. Intravitreal anti-vascular endothelial growth factor injection can be an effective treatment in such cases. To the best of our knowledge, this is the first report of simultaneous bilateral CNV associated with infective endocarditis.
Infective endocarditis is a life-threatening infection of the heart valves or endocardium. The incidence of visual disturbance in patients with endocarditis is approximately 5%. Causes of visual disturbance include Roth’s spots, retinal artery occlusion, subretinal abscesses, endophthalmitis, choroiditis, and optic neuritis. Unilateral choroidal neovascularization (CNV) has also been reported. Till date, however, simultaneous bilateral CNV associated with infective endocarditis has not been reported. Here we report a rare case involving a middle-aged man who developed simultaneous bilateral CNV associated with Staphylococcus aureus infective endocarditis.
A 35-year-old man with a history of chronic otitis media presented with fever, dizziness, and fatigue. His body temperature was 39.4 °C, heart rate was 112 beats/minute (tachycardia), and systolic/diastolic blood pressure was 55/41 mmHg (hypotension). A blood test showed an increased C-reactive protein (CRP) level (11.95 mg/dL) and leukocytosis (17,470/mm 3 ). Transthoracic echocardiography revealed vegetation (16 × 7 mm) at the anterior commissure of the mitral valve. Two sets of blood cultures grew methicillin-susceptible S. aureus , and the patient was diagnosed with sepsis associated with acute infective endocarditis. One day after his presentation, a cardiothoracic surgeon performed mitral valve replacement surgery, following which the patient received daily treatment with intravenous cefazolin (6 g) in 3 divided doses every 8 hours for 7 days. His fever gradually subsided.
Fourteen days after surgery, the patient reported acute onset of visual disturbance in both eyes. Examination revealed a decreased visual acuity (VA) of 20/50 in the right eye and 30/50 in the left eye (previous VA was 20/20 in both eyes). The anterior chamber and vitreous were quiet in both eyes. Fundus examination revealed a round, elevated, yellowish lesion with hemorrhage at the fovea in the right eye and white, round spots at the posterior pole in the left eye ( Fig. 1 ). Fluorescein angiography (FA), spectral-domain (SD) optical coherence tomography (OCT; SD-OCT), and OCT angiography confirmed the presence of a single CNV area with exudation in the right eye and three CNV areas in the left eye ( Fig. 2 ). Indocyanine green angiography (ICGA) for both eyes revealed distinct CNV networks in the early phase and multifocal hypofluorescent lesions in the late phase ( Fig. 3 ).