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Keep an eye on the heart
  1. A Chandra1,
  2. E Scott2,
  3. A Chandra3
  1. 1
    Moorfields Eye Hospital, London, UK
  2. 2
    Emergency Department, King’s College Hospital, London, UK
  3. 3
    Imperial College London, UK
  1. amanchandra{at}

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A 43-year-old man had 15 recurrent episodes of pyrexia associated with rigors responsive to oral penicillin over a period of 15 months. He had no other medical history or foreign travel. During his latest episode he mentioned that he had a red patch in the centre of his right visual field. Examination revealed a Roth spot over the fovea (fig 1), a pan systolic murmur radiating to the axilla and splinter haemorrhages within the right big toenail (fig 2). Echocardiography exposed vegetation attached to the posterior mitral valve leaflet. Subacute bacterial endocarditis should not be forgotten in pyrexia of unknown origin. Although Roth spots are unusual over the fovea, this patient’s subsequent visual disturbance highlighted his underlying pathology.

Figure 1 White centred Roth spot over right fovea.
Figure 2 Splinter haemorrhage over right big toe.


This article has been adapted from Chandra A, Scott E, Chandra A. Keep an eye on the heart Emergency Medicine Journal 2008;25:380


  • Competing interests: None declared.

  • Patient consent: Patient consent has been received for publication of the details of this case.