Systemic Complications of Infective Endocarditis
A 49-year-old male was brought to a local emergency department from a hotel after being found by hotel staff to have confusion, speech difficulty, and left-sided weakness. A head CT scan revealed multiple infarcts, and he was transferred to a tertiary care facility for further care. On arrival, the patient was febrile (39°C) and hypotensive and appeared alert, but he was unable to follow commands and had a left-sided hemiparesis. On auscultation, a soft, early diastolic murmur was best heard at the apex. Examination of the skin revealed numerous petechiae, bilateral splinter hemorrhages (Figure, panel A) and multiple small, peripheral necrotic lesions on his feet. An ophthalmologic examination revealed conjunctival petechiae and multiple bilateral retinal hemorrhages, without any typical Roth’s spots (Figure, panel B). Review of the patient’s medical records revealed a history of atopic dermatitis recently treated with immunosuppressive medications, including cyclosporin and mycophenolate. A emergent transesophageal echocardiogram at admission demonstrated an ejection fraction of 30%, severe aortic regurgitation and multiple vegetations, a 14×6-mm vegetation on the anterior cusp of the aortic valve (Movie I, Data Supplement) and a 17×6-mm vegetation on the anterior mitral leaflet (Figure, panel D, arrow; Movie II, Data Supplement). The patient required inotropic and ventilatory support and was started on gentamicin, nafcillin, and vancomycin. Multiple blood cultures grew methicillin-sensitive Staphylococcus aureus. The patient’s mental status did not improve, and an MRI scan showed multiple infarcts involving multiple vascular distributions (arrows in Figure, panel C) including right frontoparietal, left parieto-occipital, right occipital, and right frontal. On the basis of the patient’s advanced directive and poor neurological prognosis, the family decided to withdraw support, and he died shortly thereafter.
The online-only Data Supplement, which contains 2 Movies, is available at http://circ.ahajournals.org/cgi/content/full/112/20/e324/DC1.