A RARE CASE OF INFECTIVE ENDOCARDITIS FOLLOWING CORONARY ANGIOPLASTY WITH AN UNUSUAL PRESENTATION OF ENDOPHTHALMITIS

Abstract

Objective: There is a rise in the global incidence of infective endocarditis due to gram-negative bacilli like Pseudomonas aeruginosa and involving structures of the left side of the heart such as valve apparatus and papillary muscles. It is due to the increasing usage of implantable cardiac devices and prosthetic valves. Occurrence of infective endocarditis following minor cardiac procedures like coronary angiography or angioplasty is extremely rare. Infective endocarditis has varied clinical presentations making its diagnosis difficult. Hence a high degree of clinical suspicion by the treating physician is essential for rapid diagnosis and treatment. Design and method: We present a case of a 54 year old man, a non-intravenous drug user with long standing history of diabetes mellitus, who underwent a per-cutaneous coronary angioplasty for a double vessel block of the coronary vasculature. Six months later he presented to the emergency room with a febrile illness. His initial blood report was positive for dengue fever. His clinical symptoms rapidly worsened over one day with development of endogenous endophthalmitis of left eye, erythema nodosum, new-onset Janeway lesions and transient glomerulonephritis. Blood and vitreous fluid cultures showed growth of Pseudomonas aeruginosa. Results: Transthoracic echocardiogram showed presence of an oscillating vegetation attached to the papillary muscle of the left ventricle, associated with moderate mitral regurgitation and new onset mitral valve prolapse. He was aggressively treated with a combination therapy of intravenous and intravitreal antibiotics. His clinical features and blood hemogram showed gradual improvement over the next four weeks, responding to medical treatment. Echocardiogram was repeated which showed no resolution in findings. As his visual acuity showed no improvement, an enucleation surgery of his left eye was planned. One day prior to the surgery, patient became unresponsive with no recordable pulse rate and blood pressure. He had developed a sudden cardiac arrest and died. Conclusions: Complications and systemic embolization are more commonly associated with the left heart infective endocarditis. Despite various advances and administration of adequate treatment, infective endocarditis is associated with a guarded prognosis. It has significantly high degree of morbidity and mortality.