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A 22-year-old woman presented with the complaint of a small, central “blurry spot” in the vision of her right eye that she had noticed for the past month. This was associated with fatigue, shortness of breath, and headaches. She denied having fevers or chills. On examination, visual acuity was 20/20 in both eyes. Funduscopic exam was notable for clear vitreous media, white-centered intraretinal hemorrhages (Roth spots) in the posterior pole, and mild vascular dilatation in both eyes.
A blood count revealed anemia (hematocrit was 17 percent) and leukocytosis (white blood cell count was 35 x 109 cells/L). A peripheral blood smear yielded immature white blood cells. A bone marrow biopsy confirmed the diagnosis of acute myelogenous leukemia. She underwent induction chemotherapy with daunorubicin and cytarabine; her visual symptoms improved within one week.
Roth spots are classically associated with subacute bacterial endocarditis but can be seen in other conditions, including leukemia, pernicious anemia, hypertensive retinopathy, and diabetes. The white center of Roth spots may consist of neoplastic cells, white blood cells, platelets, fibrin, or focal ischemia. White-centered retinal hemorrhages are more common in acute than chronic leukemias and tend to be located in the posterior pole. The Roth spots in this patient likely contained neoplastic white blood cells. This image depicts early clearing of the Roth spots one week into chemotherapy.
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