PGY2 Edward Cho presented a case of a 37-year-old M with history of IV drug use and endocarditis s/p aortic valve/mitral valve replacement and L lower extremity thromboembolism s/p fasciotomy who presents to ED with acute onset 10/10 non-radiating L sided chest pain x3 days. He was in his usual state of health until 3 days prior when he woke up with the pain. The chest pain is constant, worsened with exertion, associated with shortness of breath, cough and fevers. Denies any sick contacts or travel. ROS also with low back pain but no saddle anesthesia or urinary/bowel incontinence. Home medications include ASA, Atorvastatin, Warfarin, Furosemide and Metoprolol tartrate. He is incarcerated and last used IV heroine 2 months ago, last ETOH use 1 week ago. Not currently sexually active.
Vitals: T 38.2, HR 145, RR 20, BP 90/72, O2 sat 94% on 4L NC
Physical Exam significant for well developed, uncomfortable and tired appearing male, diaphoretic, tachycardic but regular with no murmur/rub/gallops, clear pulm exam, mild tenderness in LUQ and mild midline and paraspinal lumbar spinal tenderness. No skin lesions noted and extremities well perfused.
CBC: WBC 10.2> Hb 14.3/Hct 41.3 <Plt 17 (MCV 89.1, RDW 16.9%)
Na 131/K 4.3/Cl 98/HCO3 19/BUN 23/Cr 1.30<Glucose 105 (baseline Cr 0.7)
ALP 142>T.protein 6.1/Albumin 3.4/AST 42/ALT 37/Tbili 1.4/Dbili 0.6
Ca 8.4, Mg 1.5, Phos 2.2
Coags: PT 15.8, INR 1.28, PTT 41.3
Infectious workup initiated, with the following findings:
- Persistent BCx positive for Serratia even after 4 days despite appropriate Abx treatment
- HIV, RPR, Fungal BCx, COVID-19 and Bronch studies with PCP, MTB PCR and Aspergillus not detected
- Hepatitis panel positive for Hep C Ab
- UA: 100 protein, moderate blood (RBC 4-5/HPF), 11-30 WBC
- CXR with no acute cardiopulmonary disease
- CT A/P: peripheral wedge shaped hypodensities in the spleen and b/l kidneys
- ABG: 7.35/34/31/18 on 33% FiO2
- Trop neg x3, Pro-BNP 4015 (normal <125)
- Both TTE and TEE negative for valvular vegatations/abnormalities
Treatment: Patient admitted to MICU for severe sepsis with severe thrombocytopenia and tachycardia. He was started on cefepime + gentamicin for pseudomonal coverage of prosthetic valve in setting of GNR bacteremia. Antibiotics escalated to meropenem + therapeutic gentamicin and it was later discontinued due to developing AKI after 2 weeks of treatment.
- Duke Criteria:
- Definite: 1 pathological crtieria OR 2 major clinical OR 1 major + 3 minor OR 5 minor criteria
- Possible: 1 major criterion + 1 minor criterion OR 3 minor criteria
- Rejected: firm alternative diagnosis explaining evidence of IE, resolution of IE syndrome with antibiotic therapy <4 days, no pathological evidence of IE at surgery or autopsy with antibiotic therapy <4 days or does not meet criteria for possible IE as above.
- Negative TEE does NOT exclude endocarditis because both TTE and TEE can miss small vegetations or vegetations that have embolized
- The classic Janeway lesions, Osler nodes and Roth spots are not always present, especially in acute endocarditis
- Class 1 recommendations by IDSA/ACA
- TTE should be performed in all cases of suspected IE
- TEE should be done if initial TTE images are negative or inadequate and there is an ongoing suspicion for IE
- If there is high suspion of IE despite initial negative TEE, then a repeat TEE is recommended in 3-5 days or sooner if clinical findings change
- Repeat TEE should be done after an initially positive TEE if clinical features suggest a new development of intracardiac complications