Virginia Research Day 2021

Infective Endocarditis in a 73 year old Female : A Case Report

Tiffany Bryan, DO and William Cox, DO

Background

Case Report Continued

Native valve infective endocarditis is uncommon, with an incidence of approximately 2 to 10 cases per 100,000 person-years (1). Infective endocarditis occurs when collagen and other molecules becomes exposed and form a thrombotic lesion. This lesion is susceptible to the colonization of bacteria, leading to further platelet and fibrin deposition to form an infected vegetation (1). There are numerous risk factors for the development of Infective endocarditis, including neoplastic disease. Overall, gram positive bacteria account for 80% of all cases of Infective endocarditis (1.) Staphylococcus aureus occurs in 35 to 45% of these cases (1,3). Staph aureus typically causes acute endocarditis with damage to cardiac valves, embolization of vegetation’s to extra cardiac sites and can progress quickly to death if untreated (2). We present a case of a 73 year old Female who had untreated squamous cell cancer for twenty years, leading to mitral valve failure secondary to Infective endocarditis. 73 yo F with PMHx significant for lung tumor s/p resection presented to the ED complaining of weakness and shortness of breath for several days. She reportedly had not seen a doctor since early 1990’s. Physical exam revealed patient was afebrile, HR of 166, RR 30, BP 121/59, 96% RA, heart irregularly, irregular rhythm, scalp with 4-5 cm hyperkeratotic nodule with erythematous base and foul odor. Pertinent lab findings obtained were significant for WBC of 18.72, Hgb 10.7 with normal MCV, Sodium 128, BUN 50, Cr2.34, GFR 20.4, Lactic acid 3.1, troponin 0.07, Procalcitonin 32.8. EKG significant for Atrial fibrillation with RVR. CXR was negative. UA negative. Blood cultures obtained in ED and patient empirically started on IV antibiotics for severe sepsis. Patient was admitted to the hospitalist team for new onset Atrial fibrillation with RVR and further evaluation of sepsis. Case Report

She was given full dose Aspirin and started on Cardizem gtt for Atrial Fibrillation. TTE obtained showed EF 60-65%, focal calcification of anterior leaflet of mitral valve with mild to moderate regurgitation, Mild pulmonary hypertension. Blood cultures returned significant for MSSA. IV antibiotics were changed due to susceptibilities. Leukocytosis worsened so ID was consulted and TEE recommended. TEE significant for anterior MV leaflet vegetation and mild regurgitation. Patient clinically improved. PICC line was placed and she was discharged on IV Gentamicin and Ancef. Patient returned about a month later to the ED with nausea, decreased appetite, LE edema, decreased urine output and abnormal labs obtained by ID. Abnormalities included WBC of 18.39, BUN 88, Cr 8.56, Lactic acid 2.3. Given her renal function, Gentamicin discontinued and Nephrology consulted for HD. Antibiotics changed per ID recommendations. Again, patient clinically improved and was discharged. Patient returned about 2 weeks later to the ED for tachycardia and shortness of breath. Labs significant for WBC 15, lactic acid 3.2. CXR significant for bilateral pleural effusions with bibasilar infiltrates. The following day, lactic acid started trending upward and patient became hypotensive. Pressors were initiated. Due to worsening respiratory distress and effort of breathing, family and patient agreed to elective intubation. Labs obtained concerning for shock liver. CT chest obtained showed multi lobar pneumonia,already on multiple antibiotics. HD had to be discontinued because of hypotension. Patient’s clinical status continued to rapidly decline. Bedside ECHO performed by Cardiologist showed preserved EF but persistent vegetation seen on mitral valve with flailing of valve leaflets causing severe mitral regurgitation resulting in cardiogenic shock. It was discussed with family that this condition was fatal and inoperable. Family proceeded with comfort care and patient ultimately succumbed to her condition

• Figure1. TEE showing large vegetation on native mitral valve

1. Chambers, H, et al. Native Valve Infective Endocarditis. The New England Journal of Medicine. 2020, 383,6. 2. Mohiyiddeen, G, et al. Infective endocarditis caused by Staphylococcus aureus in a patient with atopic dermatitis: a case report. Journal of Medical Case Reports. 2008, 2, 143. 3. Cahill, T, et al. Infective endocarditis. The Lancet. 2016, 387, 10021. 4. Bruno Hoen, M.D., Ph.D., and Xavier Duval, M.D., Ph.D. Infective Endocarditis. New England Journal of Medicine. 2013, 368,1425-1433 This case represents an example of a neoplastic process causing infective endocarditis. In this particular situation, squamous cell carcinoma of her scalp was left untreated for at least 20 years. As mentioned earlier, Staph aureus is the most common organism that causes acute endocarditis, leading to cardiac valve damage and ultimately, failure (1,2,3). By the time this patient sought care, her mitral valve was already failing and was not repairable, leading to her fatality .

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This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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