Subacute Endocarditis Research Articles

AN UNUSUAL CASE OF SUBACUTE BACTERIAL ENDOCARDITIS PRESENTING WITH CATASTROPHIC SUBARACHNOID HEMORRHAGE

AN UNUSUAL CASE OF SUBACUTE BACTERIAL ENDOCARDITIS PRESENTING WITH CATASTROPHIC SUBARACHNOID HEMORRHAGE

Infective Endocarditis in Hypertrophic Obstructive Cardiomyopathy After Etonogestrel Implant Removal

The modified Duke criterion "predisposing heart condition" is poorly defined, and is based on outdated studies of the epidemiology of infective endocarditis (IE).Hypertrophic obstructive cardiomyopathy (HOCM) is not classified as a modified Duke criterion for the diagnosis of IE but is associated with a higher incidence of IE nonetheless. The presence of a cardiovascular implantable electronic device (CIED) is independently associated with an increased risk of IE. Patients with HOCM may be candidates for the implantation of an automated internal cardiac defibrillator (AICD) for the prevention of sudden cardiac death. Previous studies of the risk of IE in patients with HOCM did not make a distinctionfor patients with CIEDs. We present a case of a 25-year-old female with HOCM and an AICD for primary prevention, who presented with sudden right-sided hemiplegia, aphasia, dysarthria, and a low-grade fever. CT angiography demonstrated large vessel occlusion of the terminal left internal carotid artery and proximal middle cerebral artery (MCA), prompting emergent treatment with mechanical thrombectomy, which achieved full recanalization and full reperfusion. Cardioembolic stroke was suspected. She had no arrhythmias, a transthoracic echocardiogram showed new mitral valve vegetation. The etiology of the stroke was determined to be septic emboli from mitral valve subacute bacterial endocarditis and two blood cultures grew staph epidermidis. Ten days prior to presentation, she had undergone removal of an etonogestrel implant in her arm, and this was the suspected source of initial bacteremia and valvular seeding. She was treated with a six-week course of vancomycin with improvement and maintained on daily minocycline as long as the AICD were to remain in place. Our patient started developing symptoms of endocarditis after the removal of her etonogestrel implant, had no other recent procedures, and had good dentition. Hence, we maintainthat this was the likely source of her initial bacteremia that led to valvular seeding and resultant IE. This is the first reported case of etonogestrel implant removal-related endocarditis. Further studies of the association between etonogestrel implant removal, transient bacteremia, and valvular seeding leading to IE are warranted. Clinicians should be reminded of the increased risk of IE in patients with HOCM. Identifying HOCM patients at higher risk for IE, i.e. dilated left atrium and/or CIEDs is easier to accomplish with current cardiac imaging techniques.

Pathogenesis, Diagnosis, Antimicrobial Therapy, and Management of Infective Endocarditis, and Its Complications.

Infective endocarditis in the adult is life-threatening. Bacterial endocarditis is an inner infection lining the heart muscle (endocardium). The scientific study of the causes of diseases is known as etiology. The agents that cause disease fall into five groups: bacteria, viruses, protozoa, fungi, and helminths (worms). Risk factors are past heart defects, damaged or abnormal heart valves, new valves after surgery, chronic hemodialysis, and immunosuppressed state (chemotherapy, HIV, etc.). Infective endocarditis is categorized into two clinical forms: bacterial acute and subacute endocarditis. Acute bacterial endocarditis is usually caused by staphylococci (staph) and streptococci (strep). And occasionally by listeria and brucella bacterial strains. Invasive medical technology has increased the responsibility of healthcare-associated infective endocarditis (HAIE). Microscopy of the disease is the chronic aggressive cells in the deeper zone of nonspecific, composed of fibrin and platelets covering colonies of bacteria. Tuberculous valvular endocarditis due to mycobacterium tuberculosis is a rare clinical entity. Syphilitic endocarditis is pathologically the cutaneous lesions of secondary syphilis. It is caused by infection with the microorganismTreponema pallidum. Fungal endocarditis is a rare and fatal condition. They are infected with fungi such as Candida albicans, Histoplasma capsulatum, and Aspergillus species. Fatal endocarditis associated with Q fever (query fever). Q fever is a chronic or prolonged disease caused by the rickettsial-like bacillus Coxiella burnetii, a rare form of rickettsia in the endocarditis. Varicella-zoster virus (VZV) infection causes chronic and repeated febrile illness. They are followed by pharyngitis, malaise, and a vesicular rash. Chronic Q fever usually manifests as endocarditis or hepatitis. The therapy given to simplify the complications is antimicrobial therapy. The medicines prescribed are ampicillin, cefazolin, ceftazidime, gentamicin, vancomycin, metronidazole, and tobramycin. High medicinal antibiotics are used to control the spread of infective endocarditis.

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

#41 Manual Validation of an Automated Tool to Extract Blood Culture and Susceptibility Data from the Electronic Health Record for Children with Acute Myeloid Leukemia

Abstract Background Children with acute myeloid leukemia (AML) receive high-intensity chemotherapy to achieve durable remission. AML chemotherapy causes bone marrow suppression resulting in vulnerability to infection, most frequently bloodstream infections (BSI). While the most commonly described organisms include Gram-negative pathogens and streptococci, the epidemiology and resistant profile of these pathogens can change. It is important to monitor the epidemiology of these infections over time to inform clinical care. Previously capture of these microbiology data required laborious manual chart reviews that are often done intermittently and with variable accuracy, limiting the impact of the results. We sought to develop and validate an automated process for extracting blood culture results, including antimicrobial susceptibility profiles for positive results from the electronic health record (EHR). Method An automated tool to extract blood culture results from the EHR (Epic Systems, Verona WI) was developed using SQL (Structured Query Language). The tool was applied to the EHR of all children with newly diagnosed AML treated at the Children’s Hospital of Philadelphia from January 1, 2011 to December 31, 2020, regardless of subsequent relapse and treatment. Data from all blood cultures (including standard, fungal, mycobacterial, and subacute bacterial endocarditis blood cultures) were captured. Manual chart review was performed by an Infectious Diseases physician to abstract the same blood culture results to determine accuracy of the automated extraction tool. The manual abstraction was considered the gold standard. The BSI epidemiology of AML patients during this time period were described to illustrate the utility of this tool. Results There were 91 children with newly diagnosed AML who received chemotherapy during the study period. Of the collected 3,150 cultures obtained and resulted, 206 (6.5%) were positive. There were 37 distinct pathogens identified (Table 1). Of positive cultures, 114 (55.3%) were reflexed to antimicrobial susceptibility testing (AST) per institutional standards. In total, 1,427 AST results were captured in the automated tool. Manual validation confirmed that concordance between the automated abstraction and chart review was 100% for the organisms grown on culture and accurately identified all AST results. The majority of organisms were Gram-positive. The most frequently identified species was Streptococcus mitis/oralis, found in 40/206 (19.4%) of positive cultures (Table 1). Of S. mitis/oralis that underwent AST, only 8/21 (38.1%) were susceptible to penicillin. Escherichia coli was the most common Gram-negative pathogen. Candida spp. accounted for 9.3% of detected pathogens, with C. krusei identified most commonly. Conclusion We developed and automated tool to extract blood culture results from the EHR of children and adolescents with AML at a single center. This tool was manually validated and found to be 100% accurate. This tool has the ability to efficiently capture the BSI epidemiology of a specific patient population at high risk for BSI. Further work is needed to confirm the accuracy of this tool at more centers. Implementation at other sites will allow this tool to be employed for various purposes including large, multicenter epidemiology research studies or quality improvement projects.

Research in Brief

Ultrasound-guided intra-articular injection of triamcinolone and lidocaine in addition to best current treatment (advice and education) might be an effective treatment option for hip osteoarthritis, according to a pragmatic single-blind trial by Zoe Paskins and colleagues. 199 patients aged 40 years or older with hip osteoarthritis and at least moderate pain were randomly assigned to receive best current treatment (n=67), best current treatment plus ultrasound-guided injection of triamcinolone and lidocaine (n=66), or best current treatment plus ultrasound-guided injection of lidocaine only (n=66). Mean improvement in hip pain intensity over 6 months (the primary outcome; 0–10 numerical rating scale) was greater with ultrasound-guided triamcinolone and lidocaine injection than with best current treatment alone (standardised mean difference −0·55 [95% CI −0·82 to −0·27]). Hip pain intensity did not differ significantly between lidocaine injection and best current treatment alone (−0·52 [−1·21 to 0·18]). One death occurred in the triamcinolone and lidocaine group, deemed possibly related to study treatment (subacute bacterial endocarditis in a patient with a bioprosthetic aortic valve).

Subacute infective endocarditis caused by Bacillus cereus in a patient with Systemic Lupus Erythematosus

A rare and difficult to diagnose case of subacute infective endocarditis caused by Bacillus cereus in a patient with systemic lupus erythematosus and Libman-Sacks endocarditis has been reported. Our aim is to highlight the importance of molecular methods such as MALDI-TOF and PCR to explain clinical and epidemiological issues about infections caused by unusual pathogen.

SUB ACUTE HAEMOPHILUS PARAINFLUENZAE ENDOCARDITIS: A CASE REPORT AND REVIEW OF LITERATURE

Haemophilus species are an infrequent cause of subacute bacterial endocarditis. They are fastidious Gram-negative bacteria belonging to the oropharyngeal microflora, and are slow-growing their growth is enhanced by the presence of carbon dioxide. Herein, we describe the case of a 19-year-old male with no relevant medical history who was admitted for fever and general symptoms and was found to have sub acute native mitral endocarditis secondary to H. parainfluenzae. He underwent successful mitral valve repair with good long term outcomes. This case also highlights the ability of a rare bacterium, Haemophilus parainfluenzae, to cause a sub acute septic process and multiple complications including septic emboli. Early identification of this bacterium from blood cultures and early transoesophageal echocardiography is essential for obtaining the diagnosis and allowing early start of adequate treatment.

Clinical effectiveness of one ultrasound guided intra-articular corticosteroid and local anaesthetic injection in addition to advice and education for hip osteoarthritis (HIT trial): single blind, parallel group, three arm, randomised controlled trial.

ObjectiveTo compare the clinical effectiveness of adding a single ultrasound guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis.DesignPragmatic, three arm, parallel group, single blind, randomised controlled trial.SettingTwo community musculoskeletal services in England.Participants199 adults aged ≥40 years with hip osteoarthritis and at least moderate pain: 67 were randomly assigned to receive advice and education (best current treatment (BCT)), 66 to BCT plus ultrasound guided injection of triamcinolone and lidocaine, and 66 to BCT plus ultrasound guided injection of lidocaine.InterventionsBCT alone, BCT plus ultrasound guided intra-articular hip injection of 40 mg triamcinolone acetonide and 4 mL 1% lidocaine hydrochloride, or BCT plus ultrasound guided intra-articular hip injection of 5 mL 1% lidocaine. Participants in the ultrasound guided arms were masked to the injection they received.Main outcome measuresThe primary outcome was self-reported current intensity of hip pain (0-10 Numerical Rating Scale) over six months. Outcomes were self-reported at two weeks and at two, four, and six months.ResultsMean age of the study sample was 62.8 years (standard deviation 10.0) and 113 (57%) were women. Average weighted follow-up rate across time points was 93%. Greater mean improvement in hip pain intensity over six months was reported with BCT plus ultrasound-triamcinolone-lidocaine compared with BCT: mean difference −1.43 (95% confidence interval −2.15 to −0.72), P<0.001; standardised mean difference −0.55 (−0.82 to −0.27). No difference in hip pain intensity over six months was reported between BCT plus ultrasound-triamcinolone-lidocaine compared with BCT plus ultrasound-lidocaine (−0.52 (−1.21 to 0.18)). The presence of ultrasound confirmed synovitis or effusion was associated with a significant interaction effect favouring BCT plus ultrasound-triamcinolone-lidocaine (−1.70 (−3.10 to −0.30)). One participant in the BCT plus ultrasound-triamcinolone-lidocaine group with a bioprosthetic aortic valve died from subacute bacterial endocarditis four months after the intervention, deemed possibly related to the trial treatment.ConclusionsUltrasound guided intra-articular hip injection of triamcinolone is a treatment option to add to BCT for people with hip osteoarthritis.Trial registrationEudraCT 2014-003412-37; ISRCTN50550256.

Abstract 17228: Not Just Another Knick In The Wall: An Unusual Case Of Multiple Arterial Aneurysms

Case Presentation: 47-year-old Liberian woman with a history of latent TB and no prior cardiac history presented with dyspnea, palpitations, and weight loss. She had fevers, tachycardia, and cervical lymphadenopathy. Cardiac exam showed widened pulse pressure, systolic and diastolic murmur, and features of heart failure. TTE showed dilated left ventricle with preserved ejection fraction, aortic root aneurysm compressing left atrium, severe aortic and mitral regurgitation, and moderate pericardial effusion with no tamponade. CT angiogram of neck, chest and abdomen showed right subclavian artery mycotic aneurysm, large left supraclavicular lymphadenopathy, multiple aortic arch, and descending thoracic aorta mycotic aneurysms. She underwent emergent surgical intervention. Intraoperative TEE revealed rupture of aortic root aneurysm into left ventricular outflow tract causing a fistula, perforated anterior mitral leaflet, and distortion of the left atrial wall. She underwent mitral and aortic tissue valve replacement, aortic root replacement, and a pericardial patch repair of the left atrial wall. Subsequently, she underwent right subclavian artery aneurysm resection, right carotid axillary bypass, and vertebral artery reimplantation. Aortic valve pathology was suggestive of endocarditis with negative cultures. Lymph node biopsy revealed non-necrotizing granulomatous inflammation with no evidence of acid-fast bacilli, fungi, and malignancy. Autoimmune workup was negative. A PET CT showed post-surgical inflammatory changes with no evidence of malignancy. Discussion: We describe an unusual case of multiple large arterial aneurysms causing severe valvular insufficiency requiring emergent surgical intervention. The patient underwent extensive workup which was unrevealing. She was treated for subacute bacterial endocarditis and suspected Bechet’s disease. Thus, the quest for a definitive diagnosis continues to elude us.

What Is the Proper Antibiotic Prophylaxis Regimen for Dental Implant Placement?

What Is the Proper Antibiotic Prophylaxis Regimen for Dental Implant Placement?

Клінічний випадок лікування підгострого ендокардиту в пацієнта після закриття оклюдером відкритого овального вікна

The role of transcatheter closure of the patent foramen ovale in the occurrence of various complications remains a controversial issue. Atrial arrhythmias and bleeding are common complications, while infectious complications are extremely rare. In this clinical case we would like to report a patient who underwent transcatheter closure of a patent foramen ovale complicated by subacute endocarditis of a fully endothelized device 5 years after surgery. A 49-year-old patient was admitted to the surgical department with diffuse chest pain, sweating and fever. Three weeks earlier the patient had a fever associated with a cold. The data of the general and biochemical blood analysis indicated the presence of an inflammatory reaction of the body. After transthoracic and transesophageal echocardiography, infective endocarditis was diagnosed. The patient underwent surgery as planned. After removal of the occluder and excision of the mitral valve cusps, implantation of a mechanical mitral valve prosthesis was performed. At the site of the removed occluder, the atrial septal defect was repaired with an autologous pericardial patch. Transesophageal echocardiography showed no residual blood flow through the interatrial septum. The postoperative period was uneventful. The patient was discharged in satisfactory condition 10 days after surgery. The total duration of the antibiotic therapy was 5 weeks. Key words: open oval window, infectious endocarditis, transcatheter closure of the defect.

Successful Treatment of Embolic Aortic Valve Endocarditis in a Patient Affected by COVID-19 Pneumonia

The COVID-19 pandemic has required reorganization of the cardiac surgery system in the Italian region of Lombardy during early 2020. As a consequence, the hub-and-spoke (H&amp;S) model was introduced to manage emergent/urgent cardiac surgery cases. In this challenging scenario, in which thousands of people were affected by the novel coronavirus, we present the case of a successful treatment of a middle-aged patient affected by both COVID-19 pneumonia and subacute aortic endocarditis. Learning objective: How to treat endocarditis during the COVID-19 pandemic.

Current Challenges in the Management of Infective Endocarditis.

Infective endocarditis is a relatively rare, but deadly cause of sepsis, with an overall mortality ranging from 20 to 25% in most series. Although the classic clinical classification into syndromes of acute or subacute endocarditis have not completely lost their usefulness, current clinical forms have changed according to the profound epidemiological changes observed in developed countries. In this review, we aim to address the changing epidemiology of endocarditis, several recent advances in the understanding of the pathophysiology of endocarditis and endocarditis-triggered sepsis, new useful diagnostic tools as well as current concepts in the medical and surgical management of this disease. Given its complexity, the management of infective endocarditis requires the close collaboration of multidisciplinary endocarditis teams that must decide on the diagnostic approach; the appropriate initial treatment in the critical phase; the detection of patients needing surgery and the timing of this intervention; and finally the accurate selection of patients for out-of-hospital treatment, either at home hospitalization or with oral antibiotic treatment.

Aortic endocarditis as a possible long-term prognostic factor in surgical aortic valve replacement.

In material and methods, the authors point out "Infective endocarditis was recognized using ICD-10 codes I33, I38 or I39" These diagnoses include: I33 Acute and subacute endocarditis, I38 Endocarditis, valve unspecified and I39 Endocarditis and heart valve disorders in diseases classified elsewhere.2 Based on this, it seems that not only patients with aortic endocarditis were included, but patients with involvement of other valves were also included.

A Case of Seronegative Pulmonary-renal Syndrome: Diagnostic and Therapeutic Challenge

BACKGROUND: Pulmonary renal syndrome (PRS) is not a single entity but is caused by varied etiologies, including anti-neutrophil cytoplasmic antibody (ANCA), associated small vessel vasculitis (such as Wegener’s granulomatosis, microscopic polyangiitis, and Churg-Strauss vasculitis), Goodpasture’s syndrome, systemic lupus erythematosus, Henoch-Schonlein purpura, cryoglobulinemia, and rare causes such as druginduced vasculitis and subacute endocarditis.&#x0D; CASE REPORT: We report a case of a 51-year-old man who was referred to our hospital with a 2-month history of breathing difficulties, mild hemoptysis, and deteriorated renal function with a serum creatinine of 269 μmol/L. Serological testing was negative for anti-neutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) antibody, and also all cultures, including blood and urine, remained negative. In the renal biopsy, not linear deposition of IgG along the GBM and crescents at varying stages with extracapillary glomerulonephritis emphasizes the possibility of a double-seronegative pulmonary renal syndrome. Regarding therapeutic dilemmas, on the 3rd day of hospitalization, we initiated immunosuppression with cyclophosphamide and corticosteroids as well as plasma exchange (5 treatments). Under immunosuppressive therapy and plasma exchange, the patient’s status continually improved; there was no pulmonary bleeding, but the serum creatinine remained high and renal function remained in stage 4 chronic kidney disease. Four weeks later, he was hospitalized again, and we faced a new therapeutic dilemma because of the rapid relapse during immunosuppressive therapy and renal function deterioration that required hemodialysis treatment. Despite repeatedly negative results for anti-GBM and ANCA, initial immunosuppressive therapy with plasma exchange (9 treatments) was included again. The patient was discharged 30 days after admission in a stable general condition, with the maintenance immunosuppressive therapy with mycophenolate mofetil and hemodialysis 3 times/week. After 24 months, we have received information from the hemodialysis center that he is on regular hemodialysis and that he is in good condition.&#x0D; CONCLUSION: We think that in this atypical case, intensive plasma exchange and immunosuppressive therapy are crucial in the early stage and maintenance therapy is necessary for vasculitis in remission. This reported case has important clinical implications because pulmonary-renal syndrome with negative ANCAs and anti-GBM antibodies is extremely rare and no treatment recommendations have been established yet.

Managements of 13 emergency cardiac surgeries under COVID-19 pandemic in a Sentinel Hospital.

BackgroundThe pneumonia outbreak caused by the 2019 novel coronavirus disease (COVID-19) creates many challenges for the healthcare sector. Currently, little is known of how the pandemic has impacted patients with cardiovascular disease. The primary focus of this study was to determine whether emergency cardiovascular surgeries can be carried out safely during the COVID-19 pandemic.MethodsBetween 17 January 2020 and 11 February 2020, 13 patients were admitted to Wuhan Union Hospital for emergency cardiovascular surgery. During this time, Wuhan was a COVID-19 epicenter, and Wuhan Union Hospital is a sentinel hospital located in this area. These patients’ epidemiological histories, clinical records, laboratory assessments, imaging findings, and surgical outcomes were retrospectively reviewed. Throat swabs were collected from some patients preoperatively and all patients postoperatively for reverse transcription polymerase chain reaction (RT-PCR) testing to determine whether these patients had COVID-19.ResultsThis cohort included 5 cases of acute aortic dissection, 3 cases of congenital heart disease, 2 cases of dilated cardiomyopathy with end-stage heart failure, 1 case of aortocoronary fistula that had undergone previous surgery, 1 case of subacute infective endocarditis with cerebral infarction, and 1 case of multivessel coronary disease. Six patients were suspected COVID-19 cases (46.2%). There were no confirmed COVID-19 cases in this cohort. None of the patients in this cohort died and none developed severe acute respiratory syndrome, renal failure, or septic shock after surgery. No cross-infection occurred with other patients or medical staff who came into close contact with this cohort.ConclusionsEmergency surgery is crucial and unavoidable for many patients with acute and severe cardiovascular disease, regardless of the pandemic. Our study indicates that, with adequate preparation and the provision of appropriate treatment, satisfactory outcomes can be achieved for such patients.

Gustav Mahler: betrayed love and endocarditis lenta

Gustav Mahler (1860-1911), a renown Austrian composer, died of subacute bacterial endocarditis, when antibiotic treatment was not yet available. Earlier in his life, he developed a mitral stenosis with systolic murmur which was a legacy of frequent throat infections and rheumatic fever which he had as a child. This condition was diagnosed accidentally when he was age forty-seven. Throughout his adult life, however, Mahler was asymptomatic and became a very successful conductor and musical director, as well as a prolific composer. His preoccupation with fate and death was notorious, probably having its roots in many deaths of his young siblings. The fatal blow came in a form of betrayal by his beloved wife, Alma, who had a love affair with a younger man. This sudden abandonment constituted a severe emotional stress, which superimposed on other past and present adverse events in his life, weakened his immune system. He developed bacteraemia-cum-endocarditis and finally succumbed to a cruel fate, a theme that repeatedly appears in his music.Key wordsMahler, endocarditis, betrayal, immune system, fate

Functional Analysis of the Collagen Binding Proteins of Streptococcus parasanguinis FW213.

Streptococcus parasanguinis is a dominant isolate of dental plaque and an opportunistic pathogen associated with subacute endocarditis. As the expression of collagen binding proteins (CBPs) could promote the establishment of S. parasanguinis in the host, the functions of three putative CBP-encoding loci, Spaf_0420, Spaf_1570, and Spaf_1573, were analyzed using isogenic mutant strains. It was revealed that S. parasanguinis FW213 bound effectively to fibronectin and type I collagen, but the strain's affinity for laminin and type IV collagen was quite low. By using various deletion derivatives, it was found that these three loci mediated the binding of S. parasanguinis to multiple extracellular matrix molecules, with type I collagen as the common substrate. Derivative strains with a deletion in any of the three loci expressed reduced binding to trypsin-treated swine heart valves. The deletion of these loci also reduced the viable count of S. parasanguinis bacteria within macrophages, especially the loss of Spaf_0420, but only strains with deletions in Spaf_0420 and Spaf_1570 expressed reduced virulence in the Galleria mellonella larva model. The deletion of Spaf_1570 and Spaf_1573 affected mainly the structure, but not the overall mass, of biofilm cultures in a flow cell system. Thus, CBPs are likely to be more critical for the initial colonization of S. parasanguinis on host tissues during the development of endocarditis.IMPORTANCE Bacteria generally can utilize multiple adhesins to establish themselves in the host. We found that Streptococcus parasanguinis, a dominant oral commensal and an opportunistic pathogen for subacute endocarditis, possesses at least three collagen-binding proteins that enable S. parasanguinis to successfully colonize damaged heart tissues and escape innate immune clearance. The binding specificities of these three proteins for extracellular matrix molecules differ, although all three proteins participate in biofilm formation by S. parasanguinis The "multiligand for multisubstrate" feature of these adhesins may explain the high adaptability of this microbe to different tissue sites.

Subacute infective endocarditis presenting as upper abdominal pain

Splenic abscess develops in 3-5% of patients with infective endocarditis. In more protracted subacute cases of infective endocarditis, symptoms and signs such as anorexia, weight loss, weakness, arthralgia and abdominal pain may occur in 5-30% of patients and thereby misleading the clinician to pursue incorrect diagnosis such as malignancy, connective tissue disease, or other chronic infection or systemic inflammatory disorders. Left upper quadrant pain can be a presenting symptom in a patient with IE, if it is complicated by septic embolization to spleen. Here reported a case of subacute infective endocarditis complicated with splenic embolization in a 34-year-old male with diabetic nephropathy and ischemic dilated cardiomyopathy, presented as acute abdominal pain.