What is the management of Roth spots?

Management of Roth Spots

Roth spots themselves require no specific treatment—management is directed entirely at treating the underlying systemic disease causing them, most commonly infective endocarditis. 1

Understanding Roth Spots as a Clinical Sign

Roth spots are white-centered retinal hemorrhages that serve as a diagnostic clue rather than a therapeutic target. 2 While historically considered pathognomonic for infective endocarditis, they are actually nonspecific immunological phenomena that can occur in multiple conditions including pernicious anemia, leukemia, essential thrombocythemia, and sickle cell disease. 2, 3, 4, 5, 6

When Roth spots are identified, they function as a minor criterion in the modified Duke criteria for diagnosing infective endocarditis under "immunological phenomena." 1

Immediate Diagnostic Workup When Roth Spots Are Present

Step 1: Suspect Infective Endocarditis First

• Look for fever (present in up to 90% of IE cases), new or changing heart murmur (present in up to 85%), and other peripheral stigmata including splinter hemorrhages, Osler nodes, Janeway lesions, and petechiae. 1, 7
• Assess for predisposing cardiac conditions: prosthetic valves, congenital heart disease, previous IE, or intravenous drug use. 1, 7
• Check for embolic phenomena affecting brain, lung, or spleen (occurs in 30% of IE patients). 1

Step 2: Obtain Blood Cultures BEFORE Antibiotics

• Draw at least 2-3 sets of blood cultures from different venipuncture sites before initiating any antimicrobial therapy. 1, 7, 8
• This is critical—starting antibiotics before adequate cultures is a major pitfall that compromises diagnostic accuracy. 8

Step 3: Perform Echocardiography

• Begin with transthoracic echocardiography (TTE) as first-line imaging. 1, 7
• If TTE is negative but clinical suspicion remains high, proceed immediately to transesophageal echocardiography (TEE) for superior sensitivity in detecting vegetations, abscesses, and valve complications. 1, 7
• TEE should also be performed even when TTE is positive to rule out local complications like perivalvular abscesses. 1

Treatment Approach for Infective Endocarditis

Antimicrobial Therapy

• Once blood cultures are obtained and if clinical suspicion is high, initiate empiric antimicrobial therapy immediately without waiting for culture results. 7, 8
• Tailor antibiotic regimen based on identified pathogen once cultures return positive. 7
• Duration of therapy typically ranges from 4-6 weeks depending on the causative organism and presence of complications. 7

Surgical Consultation

• Obtain early surgical consultation for all complicated IE cases, which include: heart failure due to valvular destruction, uncontrolled infection despite appropriate antibiotics, prevention of embolic events, or large vegetation size (>10mm). 7, 8

Multidisciplinary Team Management

• Refer complicated cases to a reference center with an "Endocarditis Team" consisting of infectious disease specialists, cardiologists, cardiac surgeons, microbiologists, and imaging specialists. 1, 7, 8
• Even uncomplicated cases managed at non-reference centers should maintain early and regular communication with reference centers. 1

Workup for Alternative Diagnoses

If IE is ruled out through negative blood cultures and echocardiography, investigate other causes:

• Hematologic disorders: Check complete blood count with differential, peripheral smear, vitamin B12 and folate levels (pernicious anemia), platelet count and JAK2 mutation (essential thrombocythemia). 3, 4, 6
• Hemoglobinopathies: Hemoglobin electrophoresis if sickle cell disease is suspected. 5
• Hypertensive retinopathy: Blood pressure measurement and assessment of end-organ damage. 2

Special Considerations

• In neonates with IE, Roth spots are rarely described and should not be expected as part of the clinical presentation. 1
• Roth spots may indicate a more prolonged, subacute course of endocarditis rather than acute presentation. 1, 8
• The presence of Roth spots alongside other immunological phenomena (Osler nodes, glomerulonephritis, positive rheumatoid factor) strengthens the diagnosis of IE. 1

Critical Pitfalls to Avoid

• Never delay blood cultures or start antibiotics before obtaining adequate cultures. 8
• Do not fail to perform TEE when TTE is negative but clinical suspicion remains high. 1
• Do not manage complicated IE cases without involving a specialized Endocarditis Team at a reference center. 8
• Do not overlook the need for early surgical evaluation in complicated cases. 7, 8