Case Presentation: A 43-year-old male presented with a 2-day history of complete loss of vision. Past medical history included alcohol use disorder. He was initially alert but became severely agitated requiring multiple doses of benzodiazepines intravenously (IV). He was afebrile and tachycardic 121. He had a moon face, centripetal obesity with purple striae, a buffalo hump and swelling and redness to both hands. Labs were significant for: WBC 14 K/UL, troponin 9 ng/ml and ferritin 1465 ng/ml. CT head and lumbar puncture were negative. There were splenic and left renal infarcts on CT abdomen. It was later revealed that he was self-administering dexamethasone IV for an acute history of undiagnosed bilateral hand swelling. A transthoracic echocardiogram (ECHO) showed 1.5 cm aortic valve vegetation and serial blood cultures were positive for methicillin sensitive staphylococcus (MSSA) confirming infective endocarditis (IE). Diffuse septic emboli involving the occipital lobes were present on MRI brain. He had aortic valve replacement and coronary sinus annular abscess repair on day 6 and was treated with Nafcillin for 8 weeks with resolution of blindness.
Discussion: Bilateral blindness due to IE is extremely rare. Only a few cases have been reported1, with etiologies including: metastatic ophthalmitis, cerebral infarction and ruptured aneurysm. Stroke due to septic embolization is the most common neurological complication of IE and emboli to both occipital lobes results in cortical blindness. Brain MRI is an important tool in identifying ischemic infarcts due to septic emboli and has superior sensitivity compared to CT, where lesions are often missed. Early intervention is crucial to decrease mortality, which can be as high as 30% in the first 2 weeks. The cornerstone of treatment is antibacterial therapy. The timing and decision to proceed with valve surgery in patients with cerebrovascular complications is a subject of debate. Two recent studies have demonstrated that early surgery effectively decreases systemic embolism without increasing the IE relapse rate, compared to conventional treatment2. Reversal of blindness is possible as seen in our case and the case by Kranidiotis et al3. Endovascular treatment of acute septic emboli is uncertain, but a few case reports have demonstrated benefit4.
Conclusions: This case highlights that a sudden neurological event in a patient, including bilateral blindness, should prompt the clinician to consider infective endocarditis. Cortical blindness from septic emboli is a rare presentation of IE and can be reversed with appropriate treatment.