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Fundus lesions from MRSA Bacteremia Jenny Xu, Resident VA Palo Alto Abstract: Cotton wool spots are non-specific clinical findings associated with different conditions, with strong association with diseases such as diabetes and hypertension that affect the microvasculature. Cotton wool spots may also present in patients with bacteremia and the presence of retinal findings may indicate the severity of the infection and the mortality of the patient. I. Case History a. Patient demographics: 62 white male b. Chief compliant: difficulty perceiving details in bright light c. Ocular history: i. Diabetes without retinopathy ii. Mild cataracts iii. Hyperopia and astigmatism d. Medical history: i. History of multiple skin Staph infections with recent hospitalization due to MRSA perianal abscess that spread to involve the prostate and paraspinal and epidural abscesses ii. Diabetes type II for the past 10 years, well controlled; last A1C 6.3% iii. Hypertension well controlled – currently not on medications, recent BP ranging from 109/54 to 154/81 iv. Basal cell carcinoma v. Hyperlipidemia – well controlled, currently not on medications vi. Coronary heart disease vii. Recent anemia due to infection viii. History of substance abuse a. Medications: IV Vancomycin and ciprofloxacin, insulin, morphine, gapapentin, II. Pertinent findings a. Clinical findings: i. BCVA: 20/30 OU ii. Refractive error: Pl+1.75x173 OD, -0.50+2.00x004 OS iii. Pupils: ERRL, -APD iv. Anterior segment findings: mild cataracts OU, otherwise unremarkable v. IOP: 12/14mmHg vi. Posterior segment: 1. ONH: small C/Ds OU, 0.1 OD, 0.2 round with nasal heaping, distinct margins 2. Posterior pole: multiple peripapillary cotton wool spots OU 3. Macula: flat, even OU b. Other tests: i. Zeiss Cirrus optic nerve OCT: RNFL and neuroretinal rim elevation OU likely from peripapillary cotton wool spots c. Pertinent laboratories: i. Positive MRSA Survl Nares DNA ii. A1C: 6.3%, blood sugar 86 to 200mg/dl iii. Complete CBC count: normal WBC count with mild anemia iv. Elevated C-reactive protein and sedimentation rates v. Negative HIV antibodies d. Pertinent radiology reports: i. MRI Lumbar/Spine: Significant dorsal epidural abscess with paraspinal and psoas abscess I. Differential Diagnosis a. Primary/leading: Diabetic and hypertensive retinopathy b. Others: i. Anemia ii. HIV retinopathy iii. Interferon retinopathy iv. Purtscher’s traumatic retinal angiography v. Lymphoma/leukemia vi. Radiation retinopathy vii. Multiple myeloma viii. Auto-immune conditions ix. Carotid/cardiac emboli II. Diagnosis and Discussion a. Retinal lesions from disseminated bacterial infections: Cotton wool spots, superficial hemes and Roth spots are the most common retinal findings. Various studies report a percentage of 5% to 15% retinal lesions in patients with bacteremia and septicemia. Given the well-controlled status of the patient’s diabetes and hypertension, as well as the lack of other retinal findings, the lesions are unlikely manifestations of diabetes and hypertension. b. Pathogenesis: Although the mechanism has not been completely elucidated, there are a few proposed mechanisms for the occurrence of cotton wool spots in patients with bacteremia and septecemia. One mechanism proposed was that the build- up of immune complexes in arteriole walls leading to arteriolar occlusion and therefore formation of the cotton wool spots. The second mechanism proposes that the sludging of the blood from the increase of fibrinogen lead to the increased likelihood of ischemic events. The third mechanism proposes that the direct infection of the blood vessel endothelial walls that causes blood vessel inflammation, which in turn leads to blood vessel abnormalities and ischemia. Still another attributes the cause to be the presence of septic emboli, may also lead to endogenous or metastic endophtalmitis. III. Treatment, management a. Treatment: There is no direct treatment of the retinal lesions other than treating the underlying infection. b. Bibliography: i. Rodriguez-Adrian, Libsen J.; King, Robert T.; Tamayo-Derat, Luis G.; Miller, John W.; Garcia, Charles A.; Rex, John H. Retinal Lesions as Clues to Disseminated Bacterial and Candidal Infections: Frequency, Natural History, and Etiology. Medicine. 82(3):187-202, May 2003 ii. Bouza et. Al. A Prospective Search for Ocular Lesions in Hospitalized Patients with Significant Bacteremia. Clinical Infectious Diseases 3(2):306-12, 2000 iii. Ilhami Celik et al. The Prevalence of Bacteraemia-related retinal lesions in seriously ill patients. Journal of Infection 52:97-104, 2006 iv. Jaworski, Charles. Morphology of the HIV Versus Diabetic Cotton Wool Spot. Optometry & Vision Science. 77(11):600-604 IV. Conclusion a. Clinical Pearls: Bouza et al. noted that ocular lesions attributable to bacteremia were present in 32% of patient who died compared to 8% in those who survived. Therefore, although there are no treatments for the retinal manifestations of bacteremia, fundoscopy may still be helpful as a marker of the severity of bacteremia and prognosis.