Cardioembolic ischemic stroke as the initial presenting complaint of a patient with acute infective endocarditis and acquired immunodeficiency syndrome

Abstract

Human immunodeficiency virus (HIV) infection is an independent predictor of ischemic stroke, especially in the younger age group. Approximately 1%–5% of HIV/acquired immunodeficiency syndrome patients develop stroke. A 16-year-old male presented with a decreased level of consciousness and a history of right-sided hemiparesis, fever, cough, and dyspnea. The patient was an intravenous drug user (IVDU). Examination revealed the following: blood pressure: 130/70 mmHg, heart rate: 124×/min, temperature 38.5°C, and respiratory rate: 26×/min. Electrocardiographic findings revealed the following: sinus tachycardia: 124×/min, right-axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy. Laboratory findings were as follows: microcytic hypochromic anemia (7.33 g/dL), leukocytosis (32.2 × 10^3/μL) with shift to the left, hyponatremia (122 mmol/L), HIV was positive, and chest X-ray showed pneumonia. Echocardiography showed vegetation in the posterior mitral leaflet, mitral regurgitation, and tricuspid regurgitation with an intact interatrial septum. Computed tomography scan revealed ischemic stroke of the left parieto-occipital lobe. HIV-infected individuals are at 1.5 times increased risk of stroke compared to those without. This case involves an IVDU and a HIV-positive young male presenting with large ischemic stroke in large-vessel territory, suggestive of embolic origin. A part of vegetation on the left side of the heart of this patient dislodged and caused a cerebrovascular accident. There was also unconfirmed suspicion of pulmonary embolism from the right side of the heart. Empiric antibiotics should be started before tailoring to the result of blood culture. Endocarditis conveys a significant risk of cerebral embolism resulting in ischemic stroke and a potentially dismal prognosis.