AN UNUSUAL CASE OF INFECTIVE ENDOCARDITIS PRESENTING AS MENINGOCOCCAL MENINGITIS IN A YOUNG MALE WITH RECENT DENTAL WORK

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Incidence of infective endocarditis (IE) has been increasing in U.S., likely due to increased age, valvular diseases and cardiac device implantation or valve replacements. Here, we present a case of infective endocarditis with uncommon presentation, unusual risk factors and rapidly progressing course that is important for clinicians to consider in their clinical practice. CASE PRESENTATION: A 39-year-old healthy man, without smoking or drug use, presented for altered mental status and fever for 1-2 days. His initial vitals were significant for a temperature of 103.8˚F. On exam, he was oriented x2, had conjunctival petechiae, a fixed dental expander, a soft systolic murmur and petechial rash over his body. CSF studies suggested bacterial meningitis, but gram stain was negative. CT head showed a subarachnoid hemorrhage. He was started on ceftriaxone, vancomycin and steroids for likely meningococcal meningitis. His blood cultures grew methicillin sensitive Staphylococcus aureus. He developed atrial fibrillation with rapid ventricular response and elevation in troponin to 41.26 ng/dL. A transthoracic echocardiogram showed a stenotic aortic valve suggestive of bicuspid valve without vegetations. CT chest/abdomen/pelvis showed infarcts within the spleen, kidneys and mesentery. His clinical condition further declined and EKG revealed a prolonged P-R interval. A transesophageal echocardiogram showed a large aortic valve vegetation and aortic root abscess. Cardiothoracic surgery was consulted for early surgical intervention with abscess drainage and aortic valve replacement. Patient was successfully discharged home with antibiotics and warfarin. DISCUSSION: The initial presentation of fever, malaise, altered mental status and petechial rash in a young person was suspicion for meningococcal meningitis. One study of patients with IE showed 6% had encephalopathy/meningitis and 4% had hemorrhages. These complications were seen particularly with vegetations ≥3cm and S. aureus infections, similar to this patient. It is imperative to have high suspicion for IE in any infected patient with generalized CNS symptoms. Our patient lacked known risk factors for IE, thus a detailed physical examination is paramount in patients with a high index of suspicion. Presence of a dental implant provided us the initial clue towards this key diagnosis. Few studies show causation of dental procedures and risk of developing IE. This is another rare example. We report successful treatment of a rapidly progressive disease with early diagnosis, appropriate antibiotics and early surgical intervention. CONCLUSIONS: A high index of suspicion is required to quickly diagnosis IE. A detailed physical examination is paramount for correct diagnosis. TEE is superior to bedside TTE in such cases. IE can be complicated with intracardiac abscesses, septic shock, and presence of SAH. REFERENCE #1: Sexton, Daniel, and Vivian Chu. "Native Valve Endocarditis: Epidemiology, Risk Factors, and Microbiology." UpToDate, 7 Oct. 2020, www.uptodate.com/contents/native-valve-endocarditis-epidemiology-risk-factors-and-microbiology?search=causes+of+enodcarditis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. REFERENCE #2: Thanavaro, Kristin L., and J.V. (Ian) Nixon. "Endocarditis 2014: An Update." Heart & Lung, Mosby, 26 Apr. 2014, www.sciencedirect.com/science/article/pii/S0147956314000788. REFERENCE #3: McDonald, Jay R. "Acute Infective Endocarditis." Infectious Disease Clinics of North America, U.S. National Library of Medicine, Sept. 2009, www.ncbi.nlm.nih.gov/pmc/articles/PMC2726828/. DISCLOSURES: No relevant relationships by Michelle Zur, source=Web Response