A 27 year old male with a past medical history of IV drug use (IVDU) presents with 9 days of fever and malaise. Over the last few days he developed a worsening cough. Today he woke up feeling extremely short of breath with a productive cough.
Vitals: T 38.4, HR 104, RR 26, SaO2 92%
General: Ill appearing but A&O x 4
CV: regular rate and rhythm, no murmur appreciated
Pulm: tachypneic with scattered crackles
Abd: Soft, non-tender, non-distended
Extremities: No nailbed hemorrhages, petechia, or nodules
CXR - Bilateral pulmonary infiltrates c/w multifocal PNA
POCUS shows questionable tricuspid valve vegetation
CT Chest shows multiple embolic infarcts
Labs: Leukocytosis, elevated CRP, otherwise non-contributory.
Three sets of blood cultures were drawn and the patient was started on vancomycin and zosyn and admitted for transesophageal echocardiogram, IV antibiotics, and further treatment of presumed endocarditis.
Take Away #1
Think endocarditis for any fever of unknown origin (FUO). Highest risk patients are IVDU, hemodialysis patients, valvular disease or replacements, and indwelling lines.
Remember subacute endocarditis can be much more insidious and should always be considered in FUO.
Take Away #2
Use Modified Duke Criteria for diagnosis
Need 2 Major, 1 Major and 3 Minor, or 5 Minor Criteria for confirmed diagnosis
Probable with 1 major and 1 minor or 3 minor
Blood culture positive for typical organisms: Strep Viridans, Strep Bovis, Staph Aureu,s HACEK organisms from 2 separate cultures or 2 drawn >12hr apart
Echo showing vegetation, dehiscence of valve of abscess
Predisposing heart condition or IVDU
Vascular findings (Janeway lesions, conjunctival hemorrhage, ICH, septic PE, other arterial emboli)
Immunologic findings- glomerulonephritis, Osler nodes, Roth spots
Blood cultures positive for other organisms
Echo consistent with endocarditis w/o meeting major criteria
Take Away #3
Native valve: Vancomycin and Cefazolin OR Gentamicin
Subacute: Vancomycin and Unasyn
Prosthetic valves: Vancomycin, Gentamicin, Rifampin
IVDU- Vancomycin and Zosyn
CNS involvement: Ceftriaxone (2g BID)
Indications for Surgery
Acute decompensated heart failure with pulmonary edema or shock
New murmur of severe Aortic or Mitral insufficiency
Echo showing valvular dysfunction
Matthew Welles, MD is a current first year resident at Stony Brook Emergency Medicine.
Edited by Bassam Zahid, MD