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Year : 2018  |  Volume : 56  |  Issue : 1  |  Page : 32-34

Cortical visual impairment following cardiac arrest in a child with Salmonella myocarditis

1 Department of Ophthalmology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
2 Department of Ophthalmology, Dadar Eye Care, Mumbai, Maharashtra, India

Date of Web Publication4-Jun-2018

Correspondence Address:
Dr. Simranjeet Aulakh
Department of Ophthalmology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai - 400 022, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_34_18

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Many patients suffering from enteric fever may face serious complications affecting any organ. Cortical blindness has been reported as a complication in three cases till date. We report a case of a 10-year-old male child, who presented with bilateral loss of vision 9 months after suffering from Salmonella myocarditis with a cardiac arrest, following which there was hypoxic insult to the brain. The child had a perception of light and was diagnosed with cortical visual impairment. As per literature search from Medline and Cochrane review, no such case has been reported in this age group till date.

Keywords: Cardiac arrest, cortical visual impairment, hypoxic-ischemic encephalopathy, Salmonella myocarditis

How to cite this article:
Aulakh S, Desai R, Bandivadekar P, Shinde CA. Cortical visual impairment following cardiac arrest in a child with Salmonella myocarditis. TNOA J Ophthalmic Sci Res 2018;56:32-4

How to cite this URL:
Aulakh S, Desai R, Bandivadekar P, Shinde CA. Cortical visual impairment following cardiac arrest in a child with Salmonella myocarditis. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2020 Jul 15];56:32-4. Available from: http://www.tnoajosr.com/text.asp?2018/56/1/32/233725

  Introduction Top

Enteric fever is an endemic disease prevalent in Southeast Asia, with an estimated incidence of 622/100,000 persons/year. Many extraintestinal complications are associated with enteric fever, leading to increased morbidity and mortality, reported to be 1%–4%.[1] Myocarditis, an established complication, is life-threatening. Several ophthalmological complications are known, namely, retrobulbar neuritis, endophthalmitis, uveitis, and encephalopathy leading to cortical visual impairment (CVI). However, literature search has found no reports on  Salmonella More Details myocarditis causing cardiac arrest leading to CVI. We report such a case in a 10-year-old boy.

  Case Report Top

A 10-year-old male child was brought to the ophthalmology outpatient department by parents, with complaints of loss of vision since 9 months. The patient was admitted to the pediatric department 9 months back in view of fever with chills and pain in abdomen, and was diagnosed with enteric fever after positive Widal titers (H-1:210). The patient was responding to intravenous antibiotics; however, developed signs of shock after 5 days. The patient was intubated and transferred to the Pediatric Intensive Care Unit (PICU), in view of cardiac arrest, for which patient was started on injection dopamine (10 μg/kg/min, in 20 ml of dextrose 5%), injection dobutamine (5 μg/kg/min), and injection adrenaline (0.4 μg/kg/min in 20 ml 5% dextrose).

Laboratory assessment revealed white blood counts of 24,100/μL, suggesting sepsis. Blood sent for culture and sensitivity to microbiology came back negative for any organism. Creatine Phosphokinase- muscle/brain (CPK-MB) levels were 74 U and electrocardiogram had features of prolonged QT interval and ST segment elevation with hypotension (60/36 mm Hg) consistent with cardiac arrest. Two-dimensional echo was also performed which revealed systolic dysfunction with regional hypokinetic areas, features consistent with myocarditis.

As fever did not subside, higher antibiotics were given along with high-dose systemic steroids (injection hydrocortisone 44 mg IV 4 times a day) for myocarditis.

During the course in the PICU, the patient developed spastic quadriparesis. A neuropediatric consult was sought and magnetic resonance imaging (MRI) brain was ordered and patient started on tablet baclofen (10 mg/day), pacitane (trihexyphenidyl, titrated weekly to 0.5 mg/kg/day in 3 divided doses), clonazepam (0.25–0.5 mg 3 times a day), syrup valproate (10 mkd in 2 doses), and syrup phenytoin (5 mkd in 2 doses). MRI brain reported mild cerebral atrophy with dilation of ventricles suggestive of hypoxic brain damage [Figure 1]. Cerebrospinal fluid was sent for microbiology and was negative for any organism. The patient was extubated after 28 days in PICU and was maintaining saturation off oxygen. No ophthalmological complaints were reported at that time, and he was discharged with proper parental counseling regarding all medication and physical therapy and regular follow-up.
Figure 1: Magnetic resonance imaging brain showing hypoxic changes

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In the ophthalmology department, thorough ophthalmologic examination was carried out. The patient had a perception of light in both eyes, but inaccurate projection of rays. External examination was within normal limits. Ocular motility was full and free in all directions. On fundus examination, there was temporal disc pallor. Flash visual-evoked potential test was ordered as patient had no fixation, and revealed minimal response to bright flash stimulus suggesting marked a reduction in bilateral optic nerve function [Figure 2].
Figure 2: Visual-evoked potential report

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  Discussion Top

CVI in children is on the rise as a result of improved neonatal care. Several previous studies enumerating etiology of CVI report perinatal hypoxia to be the leading cause. Other causes include cerebrovascular accident, meningitis, encephalitis, acquired hypoxia, hydrocephalus, and head trauma.[2]

Among population suffering from enteric fever, 1%–5% may develop cardiovascular complications that increase morbidity and mortality.

The patient was diagnosed with enteric fever and started on appropriate antibiotic therapy. However, the patient suddenly went into shock as a result of cardiac arrest due to Salmonella myocarditis. Blood culture reports in  Salmonellosis More Details may not always be positive, as several factors play a role in determining test results. Several factors determine the test result, namely timing of sample collection, the amount of blood collected, storage, and transportation methods and previous antibiotic use.[3] Thus, even though the blood culture in our patient was negative, it did not rule out Salmonella bacteremia, as the patient was already on potent antibiotics for several days before testing.

Another point to be mentioned is that the patient was referred for ophthalmology consult 9 months after the primary neurological insult. Visual outcome in cases of CVI depends on early diagnosis and management. Furthermore, the level of visual impairment at the time of presentation plays an important role in determining prognosis.[4]

According to Richard et al., who conducted a study on etiology, prognosis of chronic CVI in children, concomitant anticonvulsant drugs may impede chances of visual recovery in such patients.[5] Our patient was on prophylactic anticonvulsants and should be considered as a plausible cause of poor visual outcome.

Till date, only three cases of vision loss attributed to encephalopathy following Salmonella have been reported.[6],[7],[8] As per our literature search, we were unable to find any case of enteric fever leading to cardiac complication causing CVI in the pediatric population.

In the myriad of extraintestinal complications caused by enteric fever, ophthalmological complications may occur and lead to significant visual disability and increase disease-associated morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Huang DB, DuPont HL. Problem pathogens: Extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis 2005;5:341-8.  Back to cited text no. 1
Huo R, Burden SK, Hoyt CS, Good WV. Chronic cortical visual impairment in children: Aetiology, prognosis, and associated neurological deficits. Br J Ophthalmol 1999;83:670-5.  Back to cited text no. 2
WHO. Background Document: The Diagnosis, Treatment and Prevention of Typhoid Fever. Geneva: World Health Organization; 2003.  Back to cited text no. 3
Chhablani PP. Cortical visual impairment, Sci J Med Vis Res Foun 2015;XXXIII:148-9.  Back to cited text no. 4
Huo R, Burden SK, Hoyt CS, Good WV. Clinical science chronic cortical visual impairment in children: Etiology, prognosis and associated neurological deficits. Br J Ophthalmol 1990;83:6670-5.  Back to cited text no. 5
Warncke K, Steinborn M, Burdach S, Baumeister FA. Acute encephalopathy in Salmonella infection. Klin Padiatr 2008;220:88-90.  Back to cited text no. 6
Cerovski B, Barisić N, Vidović T, Petricek I, Cerovski J. Bilateral amaurosis caused by Salmonella enteritidis infection. Coll Antropol 2004;28:927-30.  Back to cited text no. 7
Kulkarni AC, Kulkarni SA. Salmonella bacteremia presenting with visual loss. J Assoc Physicians India 1995;43:69-70.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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