Medstar Georgetown University Hospital Washington DC, DC
Stavros A. Doumas, MD, MSc1, Albert C. Shu, MD1, Bren Davis, MD1, Saraa Khan, MD1, Veronica Nguyen, MD1, Amol S. Rangnekar, MD2 1Medstar Georgetown University Hospital, Washington, DC; 2MedStar Georgetown University Hospital, Washington, DC
Introduction: The incidence of various infections in the setting of cirrhosis remains to be defined, and it is unclear whether liver dysfunction predisposes to specific infections. Reports in the literature suggest that liver dysfunction might be a significant risk factor for bacterial endocarditis. In this light, we present a case of a young patient with acute bacterial endocarditis complicated by endophthalmitis in the setting of AIH-induced cirrhosis.
Case Description/Methods: A 31-year-old female with a history of autoimmune hepatitis (AIH) complicated by cirrhosis presented with one day of vomiting, headaches, and fevers. The patient recently developed mild pancytopenia secondary to azathioprine and was switched to tacrolimus. Her admission Model for End-Stage Liver disease (MELD-Na) score was 21. On the first day of hospitalization, the patient endorsed blurry vision with associated eye pain and photophobia. Admission blood cultures grew methicillin-resistant Staphylococcus Aureus (MRSA). Careful examination of the extremities demonstrated characteristic Janeway lesions. An echocardiogram was significant for a thickened mitral valve with associated trace mitral regurgitation. Dilated eye examination revealed bilateral Roth spots, intraretinal hemorrhages/infiltrates, and findings consistent with endophthalmitis. The patient was initiated on intravenous vancomycin and received a left intravitreal vancomycin injection. Her condition gradually improved over two weeks, and she was discharged on a 6-week course of IV vancomycin and close ophthalmological follow-up. She completed her antibiotic course with daptomycin as she developed vancomycin-induced drug rash and acute kidney injury. Post-antibiotic fundoscopic examination demonstrated complete resolution of her eye infection and associated retinal findings.
Discussion: We present a case of acute MRSA endocarditis complicated by endophthalmitis in a patient with cirrhosis secondary to AIH while on immunosuppression. This case underlines that cirrhosis, especially in the setting of immunosuppression, can predispose to significant and uncommon infections in the absence of traditional risk factors. The acuity of the patient's presentation and the propensity to develop severe and rare complications (endophthalmitis) indicates that these patients might have worse clinical outcomes. Those observations support previous reports in the literature. Clinicians should have a low index of suspicion to consider infectious endocarditis in cirrhotic patients.
Figure: A. Right foot with characteristic Janeway Lesions (white arrow). B. Left palm with a single prominent Janeway lesion (white arrow). C. Color fundus photographic of the right eye with an eyelash (*) obscuring the view and light artifact (**). The vitreous clear and macula are flat but a few scattered septic emboli (white arrows) are evident along with tortuous vessels. D. Color fundus photographic of left eye with an eyelash obscuring the view. There is evidence of vitritis. The macula is flat with a small associated hemorrhage (perpendicular white arrow). Vessels are tortuous. There is a prominent Roth spot (long white arrow) along the inferior arcade with a few scattered septic emboli (horizontal short white arrows). E. Magnified color fundus photographic of left eye demonstrating a single prominent Roth spot (white arrow).
Disclosures:
Stavros Doumas indicated no relevant financial relationships.
Albert Shu indicated no relevant financial relationships.
Bren Davis indicated no relevant financial relationships.
Saraa Khan indicated no relevant financial relationships.
Veronica Nguyen indicated no relevant financial relationships.
Amol Rangnekar indicated no relevant financial relationships.
Stavros A. Doumas, MD, MSc1, Albert C. Shu, MD1, Bren Davis, MD1, Saraa Khan, MD1, Veronica Nguyen, MD1, Amol S. Rangnekar, MD2. B0575 - Staphylococcus Aureus Endocarditis Complicated by Endophthalmitis in a Young Patient with Cirrhosis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
