Bilateral Nongranulomatous Uveitis with Infective Endocarditis
A 32-year-old male presented tender papulopustules (Osler's node) on the pulp of right 2nd and left 3rd fingers for 14 days since June 2010. The patient had intermittent fever without any underlying systemic diseases. In July 2010, the patient was admitted to our institution, and physical examination revealed a grade III/IV pansystolic murmur over the apex. Transthoracic and transesophageal echocardiography showed vegetation in the anterior leaflet of the mitral valve and severe mitral regurgitation. Blood sample testing showed elevated erythrocyte sedimentation rate (91 mm/hr) with normal range anti-streptolysin O (ASO), and blood cultures were positive for Streptococcus parasanguinis (α-hemolytic streptococcus). With the diagnosis of IE, intravenous vancomycin 1 gm was injected every 12 hours for 4 weeks during hospitalization.\nThe patient complained of photophobia and blurred vision in both eyes 2 days after admission. Best-corrected visual acuity (BCVA) was 20 / 32 in both eyes. The biomicroscopic examination showed 2+ cells in the anterior chamber without keratic precipitates and vitritis in both eyes. Fundus examination showed optic disc swelling with multiple retinal hemorrhages with pale centers (Roth spots) (). Fluorescein angiography showed hyperfluorescence in the optic disc and hypofluorescence in the Roth spots in both eyes (). Goldmann visual field test showed Seidel scotoma in the right eye and paracentral scotoma in the left eye.\nSerologic test for uveitis were negative including HLA B-27, antinuclear antibody, antinuclear cytoplasmic antibody, angiotensin converting enzyme, rheumatoid factor, and Venereal Disease Research Laboratory test. Pathergy test for Behcet's disease was also negative. With the diagnosis of bilateral nongranulomatous uveitis with optic disc swelling in IE, the patient was given topical 1% prednisolone acetate every 4 hours and cylcoplegics. In addition, the patient received a 40 mg (1 mL) posterior sub-Tenon injection of triamcinolone (Triam; Dongkwang Pharmacy, Seoul, Korea).\nAt 1 week after triamcinolone injection, BCVA increased to 20 / 20 in both eyes. Cells in the anterior chamber and vitritis resolved within 4 weeks after the injection. The fundus showed complete resolution of disc swelling with decreased retinal hemorrhages in both eyes.