A 29 years old presented in emergency department with high grade fever with rigor and chills and acute confusional state

A 29 years old presented in emergency department with high grade fever with rigor and chills and acute confusional state. Examination was notifiable for a GCS of 13/15. Temperature of 102^oF, heart rate of 130 beats per minute with regular pulse, respiratory rate of 28 per minute, diaphoresis, Grade 2/6 diastolic murmur at left lower sternal border heard on leaning forward and bibasilar crackles. ECG showed sinus tachycardia and chest x-ray showed vascular congestion and right sided alveolar infiltrates. Baseline labs were significant for TLC of 18000 (86% neutrophils), elevated CRP and creatinine of 0.6 mg/dl. Culture result as awaited:

a) What is the most probable diagnosis?

b) What is Osler’s Triad?

c) What empirical antibiotic will you use?

d) What is sensitivity and specificity of trans-esophageal echocardiography in this case and what are the possible expected findings?

e) When will you consider surgical intervention?

Answers:

a.      Infective Endocarditis
b.      Streptococus pneumponia accounts for 1 to 3% of native valve endocarditis, and it may present as a part of the “Osler Triad”, which also include pneumococcal pneumonia and meningitis
c.       Native Valve Endocrditis: Vancomycin + Gentamicin, PVE: Vancomycin + Gentamicin+ Rifampin
 
d.      TOE detection Sensitivity is 87% and Specificity 95%, vegetations on valves, myocardial abcess
 
e.      Indications for Surgical Intervention:

• Acute Native Valve IE presenting with valve stenosis or regurgitation that results in heart failure 
• Acute Native Valve IE presenting with AR or MR with hemodynamic evidence of elevated LVEDP or LAP 
• Native valve endocarditis caused by fungal or highly resistant organisms 
• Native valve endocarditis complicated by heart block, annular aor aortic abcess,or destructive penetrating lesions
• Prosthetic Valve IE presenting with heart failure 
• Prosthetic Valve IE presenting with dehiscence confirmed by fluoroscopy or echocardiography 
• Prosthetic Valve IE presenting with increasing obstruction or worsening regurgitation
• Prosthetic Valve IE presenting with complications such as abscess formation

References:

1. Chapter 19, page 327 – Infective endocarditis - Manual of Cardiovascular Medicine Fourth Edition - Brian P. Griffin MD FACC
2. Evangelista A, Gonzalez-Abuja’s M. Echocardiography in infective endocarditis. Heart. 2004;90:614–7. doi: 10.1136/hrt.2003.029868. [PubMed]