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Visual Consequences of IV Heroin Induced Infective Endocarditis
Kathleen Abarr, OD, MS
VA Boston Healthcare System, Brockton Campus
Abstract: This case examines a young patient with a history of heroin abuse who develops recurrent
infective endocarditis, which metastasizes to his brain causing occlusive disease from septic emboli and
mycotic aneurysms with resulting visual sequelae.
Case History:
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30 year old white male
Chief complaint: Pt reports “black spot up and to the left” which began ~1 mo ago. Reports
episode of transient L eye blurriness with L arm numbness lasting a few minutes ~2 mo ago
(while using heroin). Reports constant and severe right sided headache.
Other information: Pt was recently admitted for management of a recurrent infective
endocarditis (IE) with IV antibiotics and antifungals
Ocular Hx: Bilateral Chorioretinitis 2 years prior (2013) in the setting of serratia bacteremia with
associated endocarditis- resolved without ocular complications
Medical Hx: Acute Onset Chronic Endocarditis; Polysubstance Abuse Disorder; Chronic Hepatitis
C; Mycotic Aneurysms; R sided CVA
Medications: Acetaminophen, Buprenorphine/Naloxone, Micafungin Injection, Penicillin G
Injection, Tramadol; recently finished course of IV Gentamycin and Vancomycin
Pertinent Findings
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Exam Findings
o VA sc 20/15- OD and OS
o Pupils: PRRL (+) trace APD OS; Anisocoria OS>OD in bright and dim (-)ptosis
o Confrontations: Left sided restriction OD and OS
o Other entrance tests: Color vision, cover tests, and EOMs WNL OD and OS.
o Posterior segment : Optic nerves healthy OU (-)pallor/papilledema ; During the first
weeks of treatment, no signs of inflammation/infection are visible. The patient
develops an intraretinal infiltrate in his left eye after 1 month of systemic treatment
with IV antibiotics and antifungals. At present, there are no signs of vitritis/ vasculitis/
choroiditis.
o HVF 24-2: Congruous left homonymous hemianopia, sparing macula
Systemic Findings
o Blood Cultures: Positive for Candida Parapsilapsis (normal human commensal yeast),
Granulicatella Adiacens (oral flora)
o Transesophageal echocardiography (TEE): Large mitral valve vegetation causing mitral
valve regurgitation
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Imaging: MRI/MRA & CTA:
 Occlusion of the right P2 segment of the posterior cerebral artery by likely septic
emboli causing a right infarction involving the occipital lobe, thalamus, and
posterior temporal lobe
 Small mycotic aneurysm overlying the region of the left inferior frontal
convexity
Differential diagnoses for a vascular stroke (CVA) in a young person
o Vascular occlusion from cardiac emboli from infective endocarditis (primary diagnosis)
o Ruptured aneurysm/congenital malformations/ carotid dissection
o Hematologic disorders
o Tumor/space occupying lesion
Diagnosis and Discussion
o Diagnosis: This patient developed a septic embolic occlusion of the right posterior
cerebral artery resulting in a large area of ischemia involving the right occipital lobe and
a portion of the posterior temporal lobe. These findings explain his congruous left
homonymous hemianopia, which spared his macula. Additionally, the patient has
developed a mycotic (or “infected”) aneurysm in his left frontal lobe, which puts him at
further risk of neurological complications from cerebral hemorrhage or expansion of the
aneurysm.
o This case is unique in that embolism from IE occurs in approximately 25 to 50 percent of
patients; however, only 1 to 5 percent of these patients will develop a mycotic
aneurysm (1).
o The patient is currently displaying early signs of retinal infiltration in his left eye, which
we are monitoring closely given his history of bilateral chorioretinitis.
Treatment/management
o Ocular/Visual Management: The patient will continue to be monitored for signs of
increased infiltration/inflammation or the development of endogenous
endophthalmitis. Treatment of the underlying systemic condition is vital for prevention
of further ocular/visual complications.
o Systemic management: This patient was admitted for management of a recurrent
subacute infective endocarditis with IV antibiotics and antifungals. He has a history of
poor outpatient compliance with anti-microbial therapy in 2013 during his last episode
of endocarditis. Short-course intravenous or oral regimens have been shown to be
ineffective in patients with IE involving the mitral valve due to highly resistant
organisms, so proper follow up with inpatient status is essential in his care (1).
o At this time, the patient is not in heart failure and is tolerating his mitral valve
regurgitation. Surgery for IE is considered high risk at this time given the patient’s
history of relapses of IV drug use, the risk of future prosthetic valve endocarditis, and
the likelihood of poor compliance with postoperative anticoagulation. He will be
monitored closely for signs of heart failure and further neurological complications.
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Conclusion
o Heroin use in the United States has reached epidemic levels, increasing from 1.6 users
per 1000 persons in 2000 to 2.6 users per 1000 persons in 2013 (2). IV drug use
predisposes an individual to IE due to the risk of injecting particulate matter along with
the drug which can cause valve damage. Microbes from the skin, drug, and syringe are
permitted direct entry into the blood stream. The use of saliva on injection equipment
or to dilute a drug further increases one’s risk of microbial infestation and vegetation
formation along damaged heart valves. Overall, the incidence of IE among injection drug
users is approximately 2-4 cases per 1000 years of drug use (3). Metastatic infection
from IE can involve the kidney, bones, brain, and eye.
Clinical Pearls: Signs or symptoms of a CVA in a young patient with a history of IV drug use
warrants suspicion for infective endocarditis. Early detection and treatment is essential to
reduce the risk of further complications
References
1. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial
therapy, and management of complications: a statement for healthcare professionals
from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council
on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke,
and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by
the Infectious Diseases Society of America. Circulation 2005; 111:e394.
2. Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use
Trends Among Heroin Users - United States, 2002-2013. MMWR Morb Mortal Wkly Rep
2015; 64:719.
3. Weinstein WL, Brusch JL. Infective endocarditis, Oxford University Press, New York City
1996.