INFECTIVE ENDOCARDITIS

Abstract

Mr S.D, a 61 year old male patient, presented to a
general hospital in London on the 5th May 2006 with a
6 week history of intermittent chills and night sweats.
No other symptoms were reported. His past medical
history included dyslipidaemia, hypertension and
a previous stroke (fully resolved). No other past
medical history of note was reported; and he had been
well and fit prior to the onset of symptoms.
At presentation, he had a fever of 38.0ºC and
on examination he had three splinter haemorrhages
and a large number of crowned teeth secondary
to extensive dental work in the past. Auscultation
revealed an ejection systolic murmur coupled with
an early diastolic murmur over the aortic area.
Of note were his laboratory tests which revealed
a raised white cell count of 14.7 (predominantly
neutrophils) and a C-reactive protein (CRP) of 37.
He had a normocromic normocytic anaemia.
Three blood cultures at different times with
varied phlebotomy sites grew Streptococcus oralis.
An admission transthoracic echocardiogram
revealed a large aortic valve vegetation. He was
started on intravenous Benzyl Penicillin 1.2 g every
four hours and Gentamicin 120 mg twice a day. A
dental review led to the extraction of three teeth.
After one week of treatment, transoesophageal
echocardiography showed a 1.2cm x 1.5cm vegetation
on the aortic valve with grade 3-4 aortic regurgitation
and a mildly dilated left ventricle.Although he was
haemodynamically stable while on the ward and his
inflammatory markers had normalised, his aortic
regurgitation worsened.
He was thus referred to a tertiary hospital in
central London and transferred on 31 May 2006 for
management of his severe aortic regurgitation.
On 1st June 2006 he had aortic valve replacement
with a 25 mm St Jude’s prosthetic valve.
He was extubated within 24 hours and
discharged from the Intensive Care Unit to the
High Dependency Unit on day two post-surgery.
He was hemodynamically stable and did not require
inotropic support.
In the ward he developed atrial fibrillation
which reverted to sinus rhythm with Amiodarone
treatment. His sternal wound healed nicely.
Echocardiogram post-surgery revealed a well-seated
and functioning aortic valve prosthesis.
Intravenous antibiotics were stopped on the 7th
of June 2006 on advice of the microbiologist and the
patient remained well on oral Amoxicillin therapy
for a further week. He was well, apyrexial and had
a normal white cell count on discharge on the
9th June 2006. He was discharged on variable
dose oral Warfarin for his mechanical aortic valve
(INR target 2.5-3.5). He was encouraged to mobilise
but avoid heavy lifting for three months.
He was seen on 2nd October 2006 in the
cardiothoracic outpatient clinic; he remained well
and described no cardiac symptoms.
Infective endocarditis depicts an infection of
the inner lining of the heart. If left untreated, it can
lead to multiple complications which eventually
culminate in longterm debility or even death. A high
index of suspicion in susceptible patients presenting
with non-specific symptoms is the key to diagnosing
and effectively treating infective endocarditis.
K. Mwamure, MBChB, MRCP, D. Hausenloy,
MBChB, PhD, The Hatter Cardiovascular Institute,
University College London and Medical School, 67
Chenies Mews, WC1E 6HX, UK and Mr Yap, MD,
FRCS (CTh), The Heart Hospital, University College
London Hospitals NHS Trust, 16-18 Westmoreland
Street, London, Greater London, W1G 6PH, UK.