Endocarditis due to Multidrug-Resistant Klebsiella pneumoniae -KPC

Abstract

Infective endocarditis (IE) is defined as a microbial infection of the cardiac endothelium, commonly involving, but not limited to, the cardiac valves. This pathology could lead to dire complications, carrying a high morbidity and a 6-month mortality of 25%. Its incidence increases proportionally with age and presents with a bimodal distribution and a frequency of 1/100,000 in young adults and 10/100,000 in patients older than 75 years. IE can be classified as native valve endocarditis or prosthetic valve endocarditis, with the former having higher incidence rates. Additionally, IE can be named as either right-sided or left- sided endocarditis, with each one displaying unique clinical features. We report a case of a 42-year-old Hispanic male patient with a medical history of intravenous drug abuser (IVDA), hepatitis C (HCV) and chronic alcohol abuse that arrived at the emergency room with an unquantified fever, myalgia and nausea for 4 days before admission. Patient was admitted to the medicine ward with a diagnosis of fever of unknown origin, hypernatremia and dehydration. Patient was initially treated with vancomycin and cefepime and hydration but after 72 h patient persisted with fever (average 38.8 °C), developed a rash on the palms of the hands and the soles of the feet and a new 2/6 murmur was noticed at the mitral area. Blood culture recovered multidrug-resistant Klebsiella pneumoniae with Klebsiella pneumoniae carbapenemase (KPC), and therapy was switched to polymyxin B and high-dose extended-infusion meropenem for 42 days. The patient improved and underwent valve replacement 8 weeks after discharge. IE must remain high on the differential diagnosis in every patient with fever of unknown origin. The physical exam must also remain as the cornerstone for diagnosis, as in this patient, where the development of a new hand rash and a new murmur altered the diagnosis, prognosis and management. IE poses a high mortality rate from common pathogens and is a difficult pathology to handle. The management of endocarditis due to a KPC is a real challenge in view of limited data and limited antibiotic options. J Med Cases. 2017;8(10):318-321 doi: https://doi.org/10.14740/jmc2912w