The Best in FOAM Education

Encountering Endocarditis

March 9, 2020

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

 

Major:

  • 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

 

Minor:

  • Predisposing heart condition or IVDU

  • Temp >38

  • 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

Treatments

  • 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

 

Left side

  • 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.

 

References:

 

Edited by Bassam Zahid, MD

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