INFECTIVE ENDOCARDITIS WITH SPINAL CORD INFARCTION

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis can present with disseminated septic emboli phenomenon. Neurological complications of disseminated infective endocarditis include spinal epidural abscess. Spinal cord infarction is a very rare complication of infective endocarditis with only two cases previously reported. We present a case with fulminant infective endocarditis with widespread septic emboli and spinal cord infarction. CASE PRESENTATION: 34-year-old male, intravenous drug abuser with recent incarceration presented with five-day history of progressive lower extremity weakness and pain associated with inability to walk, lower back pain, loss of bowel and bladder control, and pleuritic chest pain. Past medical history was significant for recurrent infective endocarditis of tricuspid valve and prosthetic tricuspid valve with recent tricuspid valve repair 6 months ago. Laboratory analysis was remarkable for leukocytosis, microcytic anemia, severe thrombocytopenia, lactic acidosis, and oliguric acute kidney injury requiring emergent hemodialysis. The patient was subsequently intubated for acute respiratory failure with worsening septic shock requiring pressor support. Transthoracic echocardiogram revealed a normal left ventricular ejection fraction. A large 4.1 x 1.6 cm mobile vegetation was noted involving the bioprosthetic tricuspid valve extending into the right ventricle associated with moderate stenosis. Blood cultures were positive for Serratia marcescens. CT chest was significant for bilateral ground-glass opacities, multiple nodular infiltrates, and cystic cavitary lesions representing septic emboli. CT abdomen was significant for splenomegaly with multiple splenic infarcts and bilateral multiple renal cortical infarcts. CT scan of spine ruled out epidural abscess. MRI could not be performed due to presence of epicardial leads. Based on above findings, patient was diagnosed with infective endocarditis with systemic shower of septic emboli to lungs, spleen, and kidneys with high suspicion of spinal cord infarction. Patient was started on empiric antibiotics on admission later adjusted to culture sensitivities. He continued to deteriorate clinically and underwent cardiac arrest within 72 hours of admission and expired. DISCUSSION: Infective endocarditis with septic emboli phenomenon can present with a myriad of clinical features. In the presence of neurological deficits, spinal cord infarction should be high in the differential and managed emergently due to its time-sensitive salvage. However, the probability of complete recovery after spinal infarction is very low; overall mortality in the first month is 25%, with long-term disability in 40-50% requiring wheelchair or chronic bladder catheterization. CONCLUSIONS: Spinal cord infarction is a rare complication of infective endocarditis with disseminated septic emboli phenomenon that requires emergent time-sensitive management with overall high mortality. REFERENCE #1: Kfoury B, Sharma D, Mansour W, Suen P, Abou Yassine A, Chalhoub M. Endocarditis to the Spine: A Rare Cause of Spinal Cord Infarction. Chest. 2017 Oct 1;152(4):A366. REFERENCE #2: Robertson, C.E., et al., Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology, 2012. 78(2): p. 114-21 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Stanislav Ivanov, source=Web Response No relevant relationships by Arsalan Wappi, source=Web Response No relevant relationships by Christopher Wood, source=Web Response