27 Nov 2020

10/28/20: Culture Negative Endocarditis

PGY2 Jason Li presented a case of a 62 year old man with no significant past medical history who presents with cough and chest pain.  He has had a productive cough x2-3months with clear sputum that is associated with fever and chills.  Denies any hemoptysis.  Cough is associated with chest pain which has worsened over the last 3 days.  Endorses dyspnea of exertion (walk for 15mins, previously no issues).  He reports poor PO intake.  He has gone to a physician and was prescribed Levaquin which he has been taking for the last 5 days.  He also reports occasional diarrhea over the last 2 weeks and significant night sweats and fever.  ROS also revealed a 20 pound weight loss.  No other home medications except Levaquin.  Family history significant for sisters with breast cancer.  He was born in Mexico and moved to US as a teenager.  He does not live near a farm or have a pet.  Previous owned a printing business before doing custodial work at a youth center.  He is a former smoker, and prior IV heroin use 40+ years ago.

Vitals: T 36.7, HR 101, RR 27, BP 136/75, O2 sat 95% on RA

Physical Exam significant for decreased breath sounds at R lung base but rest of exam normal.

CBC: WBC 11.5> Hb 12.1/Hct 35.0 <Plt 127 (MCV 91.1, RDW 16%)

CMP:

Na 133/K 4.2/Cl 104/HCO3 20/BUN 13/Cr 0.93 <Glucose 101

ALP 98>T.protein 6.1/Albumin 2.9/AST 85/ALT 97/Tbili 1.6/Dbili 0.5

Coags: PT 15.7, INR 1.27, PTT 31.8

CXR shows L > R ill-defined hazy opacities predominantly peripherally and at the bases.  No pleural effusions.

Given concern for pulmonary embolism due to the tachycardia and tachypnea, a CTPA was obtained which showed bilateral pulmonary segmental emboli in the lower lobes, bilateral consolidative opacities predominantly in the lower lobes and a 2.2cm R infrahilar masslike consolidative opacity which extends into and narrows the lumen of the RLL segmental pulmonary artery.

Given the chronic nature of the patient’s symptoms, infectious workup was initiated.  BCx, UCx, Fungal culture, COVID-19, HIV and RPR negative.  Procal slightly elevated at 0.93.  Communicable pulmonary TB initiated and was negative for AFB x3 and MTB PCR x2.  Fungal serologies (Aspergillus, Blasto, Cocci and Histo) all performed and was negative.  UA showed with 11-25 RBC even upon repeat. 

A Glomerulonephritis workup initiated and ANCA was negative and complement at normal levels. 

An TTE was obtained which showed a 1.2cm vegetation on the tricuspid valve with moderate regurgitation.  TEE confirmed a 1.5×1.2cm vegetation on the atrial side of the anterior leaflet of the tricuspid valve. There was severe aortic valve regurgitation.

Further serologies sent with Coxiella IgG positive and Bartonella Henselae IgG titer elevated at 1:64.

Treatment: Patient was started on heparin gtt for treatment of PE upon admission. Given persistent fevers during the hospitalization, the patient was started on broad spectrum antibiotics while pending further workup.  After TTE showed endocarditis, CTS was consulted and patient was transferred to CTS service for operative management.

Teaching points:

  1. Persistent microscopic hematuria in the UA in a patient with persistent constitutional symptoms warrants glomerulonephritis workup with ANCA and complement levels.  Low complement levels can be seen in systemic disease such as endocarditis (about 50% of the time), SLE and cryoglobulinemia.
  2. Modified Duke’s Criteria for diagnosing endocarditis

Relevant literature:

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