Infective Endocarditis Manifesting as Severe Elevation in Serum Aminotransferases in the Absence of Severe Tricuspid Regurgitation, Heart Failure, or Shock: A Diagnostic Challenge.

Eluwana A Amaratunga,Emily B Ernst,Richard Snyder,Mathai Chalunkal,Jason A Hoggard,James Kamau

doi:10.7759/cureus.16044

Abstract

Infective endocarditis (IE) is a challenging condition to diagnose, given its protean clinical signs and symptoms, Elevation in serum aminotransferases in IE is associated with valvular regurgitation, acute heart failure, or congestive hepatopathy. Studies show co-existing liver failure portends worsening outcomes in IE and poses a challenge for successful surgical management. Here we report a diagnostic challenge in a 35-year-old man with IE presenting predominantly with gastrointestinal symptoms and severe elevation in serum aminotransferase. The degree of aminotransferase elevation in our patient prompted consideration of alternative causes like acetaminophen toxicity. Severe elevation in aminotransferases as an initial presentation in the absence of significant valvular regurgitation, acute right heart failure, or shock is uncommon. A high degree of suspicion is required to diagnose IE when patients present with atypical signs and symptoms to avoid delay in initiation of antibiotics and improve overall morbidity and mortality.

Highlights

Infective endocarditis (IE) is a relatively common condition with an incidence of 3 to 10 per 100,000 persons per year and rising [1,2,3]
We report a case of IE with an initial presentation of predominantly gastrointestinal symptoms with severe elevation in aminotransferases without evidence of right-sided heart failure, congestive hepatopathy, or septic shock
Despite having a history of hepatitis C and intravenous drug use (IVDU) in this patient, the initial presentation was extremely atypical such that the initial management focus was for possible acetaminophen toxicity

Summary

Introduction

Infective endocarditis (IE) is a relatively common condition with an incidence of 3 to 10 per 100,000 persons per year and rising [1,2,3]. We report a case of IE with an initial presentation of predominantly gastrointestinal symptoms with severe elevation in aminotransferases without evidence of right-sided heart failure, congestive hepatopathy, or septic shock. A 35-year-old man with a history of IVDU and chronic hepatitis C presented with epigastric pain, nausea, and diarrhea for four days He denied fever, chills, chest pain, dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. He took four tablets of acetaminophen 325 mg for abdominal pain one day before presentation with no relief On admission, he met the criteria for systemic inflammatory response syndrome (SIRS) with tachycardia (113 beats per minute), tachypnea (20 breaths per minute), leukocytosis of 19.89 thousand/uL white blood cells, and a lactic acidosis of 3.8 mmol/L. Due to the presence of ongoing liver failure and extensive valvulopathy requiring major cardiac surgery, he was transferred to a tertiary facility for further management by cardiothoracic surgery

Discussion

Conclusions

Disclosures