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 102oF, 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 Endocarditisb. 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:
- Chapter 19, page 327 – Infective endocarditis - Manual of Cardiovascular Medicine Fourth Edition - Brian P. Griffin MD FACC
- Evangelista A, Gonzalez-Abuja’s M. Echocardiography in infective endocarditis. Heart. 2004;90:614–7. doi: 10.1136/hrt.2003.029868. [PubMed]
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