Cardiovascular Shower Infective Endocarditis Causing Multiple Septic Emboli: A Case Report and a Review of Related Literature

Abstract

Infective endocarditis (IE) is the infection of the endocardium or valves of the heart. Morbidity and mortality rates are high if not recognized early and left untreated. Complications such as heart failure, embolism and aneurysmal formation further increase mortality risk. We present a complicated case of IE where these complications co-existed in a single patient. A 27-year-old male diagnosed with rheumatic heart disease (RHD) presented with 3-month history of febrile episodes and 1-week history of left-sided weakness and facial asymmetry. Physical examination revealed subconjunctival hemorrhages, left-sided hemiparesis and left central facial palsy. On auscultation, he had murmurs suggestive of mitral regurgitation and stenosis, and aortic regurgitation. Two-dimensional echocardiography revealed mitral and aortic regurgitation with multiple large-sized vegetations at both valves. Further workup showed a right middle cerebral artery (MCA) infarct, right MCA mycotic aneurysms, and bilateral kidney infarcts with secondary infectious glomerulonephritis and splenic infarct. Blood cultures were negative. He was managed as culture-negative definite IE and was started on ceftriaxone and gentamycin which was later shifted to vancomycin due to lack of clinical improvement. During the course, he also developed severe abdominal pain - CT angiography of the abdomen revealed acute mesenteric ischemia of the superior mesenteric artery, which was managed conservatively. Double valve replacement was contemplated, but acute respiratory failure from hospital-acquired pneumonia posed higher surgical risks. Unfortunately, the patient eventually succumbed to brain herniation from new-onset multiple cerebral infarcts. Literature suggests rarity of multiple complications of IE occurring in a single patient. Because high mortality associated with complications can be averted by early recognition and early intervention, multiple embolisms should be suspected in a patient who already presented embolism in one organ-system.




J Med Cases. 2018;9(8):246-251
doi: https://doi.org/10.14740/jmc3102w