COTW 1/28/22: A 60 year old female with fever

A 60 year old F presented to the ED with 2 weeks of subjective fevers. Patient reported non-specific shortness of breath. She denied dyspnea on exertion, orthopnea, chest pain, palpitations, skin rashes, cough or ill contacts. COVID/flu tests were negative. Initial vital signs in the ED were HR 114, BP 130/65, RR 13, T 101.5, O2 sat 100% RA.

Point of care ultrasound echocardiography was performed:

Parasternal long view shows irregular thickness along the posterior leaflet concerning for vegetation

Apical 4 chamber shows vegetation along the posterior mitral leaflet

Point of care ultrasound revealed vegetation on the posterior mitral leaflet on the atrial side of the valve. Vegetations are usually seeded on the atrial aspect of the valve. Patient was started on broad spectrum antibiotics to treat native-valve endocarditis. Consultative TTE confirmed diagnosis of infective endocarditis. When endocarditis is suspected, obtain:

1. Peripheral blood cultures X3

2. CXR/CT chest if septic pulmonary emboli is suspected

3. TEE

When concerned for endocarditis evaluate potential loci of infection (pacemaker, indwelling catheters), maintain suspicion with new regurgitant murmurs or evidence of embolic phenomenon (i.e. splinter hemorrhages, conjunctival petechiae, Janeway lesions, Osler nodes) or metastatic infection (i.e. joint or spinal infections, splenic abscess).

Clinical Presentation:

1. Left-sided endocarditis: fever, flu-like symptoms, septic shock, heart failure, systemic emboli (stroke, kidney infarct)

2. Right-sided endocarditis: fever, pulmonic septic embolic

Indications for surgery:

1. Acute heart failure 2/2 valvular dysfunction

2. Heart block

3. Abscess

4. Persistent fevers for more than 7 days with positive blood cultures

5. Vegetation >15 mm or > 10 mm PLUS evidence of septic emboli despite IV antibiotics

Empiric Treatment:

1. Native valve

   1. Acute: vancomycin + ceftriaxone (alt: daptomycin)

   2. Subacute: vancomycin + amp/sulbactam OR ceftriaxone

2. Prosthetic valve

   < 1 year: vancomycin + cefepime + gentamicin

   >1 year: vancomycin + cefazolin/ceftriaxone + gentamicin

3. IV drug use

   vancomycin + piperacillin-tazobactam

Patient had an uneventful hospitalization and was discharged home with PICC-line and regimen of IV antibiotics.