Ocular symptoms and signs as presenting features of endocarditis caused by Streptococcus bovis II

Abstract

A previously healthy 76-year-old man was referred to the uveitis clinic at Moorfields Eye Hospital with a 2-month history of bilateral painless blurred vision and floaters. He had undergone intraocular surgery on his left eye a long time ago after trauma to remove a cataract. He also complained of generalized arthralgia, night sweats and headache. On examination, both eyes had a visual acuity of 6/6 and normal pupillary reactions. Slitlamp biomicroscopy showed no evidence of anterior uveitis. Funduscopy revealed few inflammatory cells in the vitreous and multifocal yellow subretinal lesions in both eyes, with a retinal haemorrhage in the right eye but no cotton wool spots or exudates and normal retinal vasculature (Figure 1). Uveitis masquerade syndrome was considered and investigations to detect lymphoma were initiated. Full blood cell count revealed normocytic anaemia with mild neutrophilia and an erythrocyte sedimentation rate of 105 mm/h. The blood film showed mild toxic granulation in some neutrophils. Renal and liver function and chest X-ray (CXR) were normal. Computed tomography (CT) scan of the brain and orbits showed no abnormality. Shortly after, his vision decreased to 1/60 in the left eye with associated increased vitritis, retinal exudates and peripheral retinal haemorrhages. The patient was systemically well, admitting no further constitutional symptoms. On examination no lymphadenopathy or abdominal masses were detected. CXR and further blood investigations including immunoglobulin screen and tumour markers were normal. A left vitreous biopsy showed predominantly chronic inflammation with a lymphohistiocytic infiltrate but no specific features of intraocular lymphoma. Since it was not possible to completely exclude lymphoma, further systemic work up was suggested. Three months after the initial presentation the patient developed lassitude, anorexia, breathlessness on exertion and progressive peripheral oedema. A repeat CXR and abdominal ultrasound showed bilateral pleural effusions and splenomegaly respectively. A new diastolic murmur was detected and infective endocarditis was considered. Echocardiography showed severe aortic regurgitation resulting from a large vegetation with depressed left ventricular function (Figure 2). Blood cultures isolated Streptococcus bovis type II sensitive to penicillin and glycopeptides. He became haemodynamically unstable despite intravenous antibiotic therapy and an urgent aortic valve replacement was undertaken. Following a 1-month course of antibiotic therapy his constitutional symptoms resolved, blood tests returned to normal and his vision improved to 6/6. Fundoscopy revealed few left vitreous debris but no signs of active inflammation or subretinal lesions. A colonoscopy to rule out associated gastrointestinal malignancy was performed and showed no abnormality.