Roth’s spots: an unusual presentation of HIV

Abstract

A 46 year old Nigerian man presented with a four week history of progressive bilateral visual loss. He had been unwell, with weight loss, fever, and night sweats for six months. Dilated fundoscopy revealed macular haemorrhages and diffuse Roth's spots. The patient was found to be severely anaemic and a bone marrow aspirate revealed a T cell lymphoma with a decreased CD4+ T cell count. The patient consented for testing for HIV which proved positive. R oth's spots do not usually involve the macula.1 2 In his original paper in 1872 Moritz Roth reported a series of patients with septicaemia and included descriptions of small white spots and separate foci of haemorrhages in the retina, which he termed retinitis septica.3 4 Roth assumed these lesions to be disseminated foci of the infective process. Six years later Litten described "white centred haemorrhages" in association with bacterial endocarditis and coined the term Roth spot. 1 CASE REPORTA 46 year old Nigerian man presented with a four week history of progressive bilateral visual loss. He also reported malaise, fever, anorexia and night sweats, and had lost 14 kg in weight. He denied any history of exposure to HIV related risk factors.Visual acuities at presentation were 6/36 in each eye with quiet anterior segments. Dilated fundoscopy revealed multiple white centred haemorrhages (Roth's spots) and large premacular haemorrhages (fig 1). There was no associated vitritis or retinitis/vasculitis. Physical examination revealed a grade III pansystolic murmur, hepatosplenomegaly, cervical and axillary lymphadenopathy, and borderline pyrexia of 37.7°C. There were no splinter haemorrhages or nail bed infarcts.Primary haematological investigations revealed a gross microcytic anaemia (haemoglobin 52 g/l). White cell and platelet counts were normal. Erythrocyte sedimentation rate and C-reactive protein were grossly raised at 120 mm/hour and 148 mg/l respectively. A presumptive diagnosis of subacute bacterial endocarditis was made, although routine and transoesophageal echocardiography were negative. Blood cultures were negative. The possibility of a myeloproliferative disorder was considered. The patient was started on empirical intravenous antibiotic therapy and underwent immediate transfusion of four units of whole blood. A bone marrow aspirate showed a T cell lymphoma with anaplastic T cells.His coagulation profile revealed an international normalised ratio of 1.23. Haematinics were normal with the exception of a grossly raised serum ferritin of 3668 µg/l. Screening for opportunistic pathogens was negative.On review one week later, the Roth's spots had decreased in number and the macular haemorrhages had begun to resolve (fig 2). A CD4+ T cell count revealed a lymphopenia of 70 cells/mm 3 . A liver biopsy specimen revealed the presence of Kupfer cells. Retrospectively, these were indicators of the presence of Mycobacterium avium intracellulare complex. The patient consented to testing for HIV and this proved positive.On review two months later, the macular haemorrhage...

Bilateral Macular Roth Spots as a Manifestation of Subacute Endocarditis

“…Depending on their number and location they can compromise the vision with varying degrees. Roth spots may be also accompanied by other retinal abnormalities such as preretinal or subhyaloid hemorrhages [ 9 , 10 ]. The OCT findings of the Roth spots include intraretinal pseudocysts and hyperreflective deposits; the latter have been described before with coexisting retinal nerve fibre layer thickening [ 4 ].…”