A 28-Year-Old Man with Impaired Vision

A 28-year-old man with acutely impaired vision, headache, and fever was referred to the emergency room because of suspected meningitis. His vital signs on admission were: blood pressure, 110/75 mmHg; heart rate, 125/min; temperature, 38.5°C. Physical examination revealed the skin changes shown in the images. Transesophageal echocardiography was performed without delay and revealed a threadlike vegetation on the aortic valve. The laboratory findings were: WBC, 14 900/µL; platelet count, 30 000/µL; CRP, 147 mg/L (normal, <5 mg/L). Antibiotic therapy with ampicillin/sulbactam and gentamicin was initiated as recommended in the pertinent guidelines; blood cultures taken beforehand were positive 24 hours later for Staphylococcus aureus. The patient’s further course was complicated by recurrent endocarditis after aortic valve replacement and by an intracranial hemorrhage extending into the ventricular system, causing hemiplegia. A bicuspid aortic valve was a predisposing factor for this patient’s endocarditis. Impaired vision is a rare initial manifestation of endocarditis and led to the initial misdiagnosis of meningitis in this case. Magnetic resonance imaging of the brain revealed numerous septic emboli as the cause of the patient’s neurologic abnormalities.

Illustration

Osler spots and Janeway lesions on the patient’s fingers and toes at the time of admission.

Dr. med. Peter Korsten, Klinik für Nephrologie und Rheumatologie, Universitätsmedizin Göttingen, [e-mail]

Prof. Dr. med. Sabine Blaschke, Interdisziplinäre Notaufnahme, Universitätsmedizin Göttingen

Conflict of interest statement
The authors declare that no conflict of interest exists.

Cite this as: Korsten P, Blaschke S: A 28-year-old man with impaired vision. Dtsch Arztebl Int 2016; 113: 662. DOI: 10.3238/arztebl.2016.0662

Translated from the original German by Ethan Taub, M.D.