P-OT021. Intracerebral hemorrhage in infective endocarditis, with dramatic response to dexamethasone: A case report

Abstract

Introduction . Intracerebral hemorrhage (ICH) in infective endocarditis (IE) patient is a rare condition. This case describes the clinical features and management of ICH due to IE with favorable outcome. Results . A 19-year-old woman, diagnosed for IE and ventricular septal defect (VSD) undergoing treatment with Levofloxacin 2 × 500 mg orally, presented to our hospital with decreased level of consciousness for 2 days following weakness of right limbs and acute communication difficulty. Physical examination: stupor, right lateralization, positive Babinski sign of right extremity. A non-contrasted head computerized tomography scan (HCTS) image revealed 20 cc ICH in the left frontotemporoparietal lobe with subfalcine herniation. Echocardiography . multiple vegetation in tricuspid valve and VSD. Streptococcus mitis/Streptococcus oralis were confirmed by the blood cultures. We prescribed 5 mg dexamethasone injection every 6 hour, tapered off after 3 days and replaced the antibiotics with Cefotaxime injection 1 gram every 8 hours. On day 14, HCTS evaluation showed improvement with 4.2 cc ICH in the left frontotemporoparietal lobe with significant improvement of the clinical state. Patient was discharged on day 39 with sequelae of UMN paresis of the 7th and 12th right cranial nerves. Conclusion . ICH in IE may be caused by hemorrhagic transformation, mycotic aneurysm rupture, pyogenic/immune complex arteritis, and/or septic emboli that causes erosive arteritis with ruptured vassels, requiring comprehensive management. Clinical improvement after administration of steroid explained the neurologic deficit was due to a vasculitis mechanism, although there are no guidelines regulate the use of steroids in IE patients with ICH. Cardiac surgery may consider to be delayed at least 4 weeks if ICH is found except there is an urgent indication.