Up to 90% of patients with infective endocarditis present with fever, often associated with systemic symptoms of chills, poor appetite and weight loss. Up to 25% of patients have embolic complications at the time of the diagnosis. Therefore, IE has to be suspected in any patient presenting with fever and embolic phenomena. Imaging, particularly echocardiography, plays a key role in both the diagnosis and management of IE. Echocardiography is also useful for the prognostic assessment of patients with IE, for its follow-up during therapy and after surgery [2]. Three echocardiographic findings are considered as the major criteria in the diagnosis of IE: vegetation, abscess or pseudoaneurysm and new dehiscence of a prosthetic valve [3].
A recent study has shown that conventional trans-oesophageal echocardiography (TOE) underestimates vegetation size and that 3D-TOE (Fig. 2B) is a feasible technique for the analysis of vegetation morphology and size that may overcome the shortcomings of conventional TOE, leading to a better prediction of the embolic risk in IE [4].
Surgical treatment is required in approximately half of the patients with IE because of severe complications. Reasons to consider early surgery in the active phase (i.e. while the patient is still receiving antibiotic treatment) are to avoid progressive heart failure and irreversible structural damage caused by severe infection and to prevent systemic embolism [5]. Embolic events are a frequent and life-threatening complication of IE related to the migration of cardiac vegetations. The brain and spleen are the most frequent sites of embolism in left-sided IE, while pulmonary embolism is frequent in native right-sided and pacemaker lead IE. The eye is a rare site for embolism in IE. Also, common risk factors for the development of endocarditis such as valvular heart disease, intravenous drug use or prior endocarditis were not present in our patient.
The period from systemic to ocular signs in EBE is short. The rapid manifestation of ophthalmic symptoms from the onset of sepsis is associated with a poorer prognosis [6] and may serve as a marker of a high virulence of the bacteria. An individual with persistent high-grade fever not responding to antibiotics should have a high suspicion of IE mandating cardiovascular examination and echocardiography to exclude any vegetation.