Roth spots

Roth spots are a funduscopic finding characterized by retinal hemorrhages with white or pale centers, seen on ophthalmologic exam. The white center represents an aggregate of fibrin and platelets, sometimes with inflammatory cells, at the site of retinal capillary rupture. While classically taught as a sign of infective endocarditis (one of the peripheral stigmata along with Janeway lesions, Osler nodes, and splinter hemorrhages), Roth spots are neither sensitive nor specific for endocarditis. They can also be seen in a variety of other conditions including leukemia, severe anemia, diabetes mellitus, HIV retinopathy, pre-eclampsia, and after cardiopulmonary bypass surgery. Pathophysiologically, they are thought to arise from immune complex-mediated vasculitis leading to vessel rupture, or from septic microemboli in the setting of bacteremia (as in endocarditis), or from capillary leukostasis and rupture (as in leukemia). Clinically, identification of Roth spots in a febrile patient should prompt evaluation for infective endocarditis, including blood cultures and echocardiography, particularly when other stigmata (e.g., new murmur, Osler nodes, splinter hemorrhages) are present. It is a classic finding tested on USMLE Step 1 and Step 2 in the context of bacterial endocarditis diagnostic criteria (part of the minor Duke criteria).