CARDIOEMBOLIC STROKE SECONDARY TO CULTURE-NEGATIVE AORTIC VALVE ENDOCARDITIS REVEALED AFTER INITIALLY PRESENTING WITH DIABETIC KETOACIDOSIS

Abstract

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Native-valve infective endocarditis (IE) has been increasing in incidence over the past several decades. This report describes a patient initially presenting with a relatively “routine” case of diabetic ketoacidosis (DKA), treatment of which unmasked an acute cerebrovascular accident, likely provoked by subacute, culture-negative aortic valve endocarditis. CASE PRESENTATION: A 67-year-old Caucasian male with a past medical history of diabetes mellitus, chronic lacunar infarctions, and hypertension was found unresponsive and in DKA at his home by EMS. Upon transfer to our intensive care unit (ICU) he was intubated and started on a DKA treatment protocol, however the patient remained unresponsive and a brain MRI revealed acute to subacute, bilateral basal ganglia and left cerebellar infarcts. Transthoracic echocardiogram revealed a 0.75 cm by 0.66 cm aortic valve vegetation, and with associated fevers and leukocytosis the patient was started on broad spectrum intravenous antibiotics. Sequential blood cultures grew no microorganisms, and autoimmune workup was negative. The patient was extubated on Day 4 but remains encephalopathic with plans for discharge to subacute rehabilitation. DISCUSSION: Literature review did not find any other cases of an insulin-dependent diabetic developing culture-negative endocarditis in the absence of intravenous drug abuse or other major risk factors. In this case, successful diagnosis hinged on acknowledging the potential for “anchoring bias”, as well as an understanding of the diagnostic criteria for infective endocarditis. CONCLUSIONS: This unusual case presentation reflects the importance of bias awareness and cognitive flexibility in developing a differential diagnosis and guiding treatment. The authors would like to acknowledge Dr. Eleanora Feketeova. DISCLOSURE: Nothing to declare. KEYWORD: Endocarditis