Clinical Practice and Cases in Emergency Medicine

Introduction: Infective endocarditis (IE) is associated with high mortality (30%). Patients with structural cardiac disease or implanted hardware have higher risk for IE (23-47%). Diagnosis per the 2023 Duke–International Society for Cardiovascular Infectious Diseases criteria is by pathological confirmation or the major/minor criteria. Major criteria include ≥ 2 positive blood culture sets, echocardiography or computed tomography vegetation visualization, and surgical visualization. Septic emboli symptoms (which complicate 25% of IE cases) include neurological deficits or shortness of breath. Early intravenous antimicrobial therapy within one hour for patients who meet sepsis criteria is recommended per Infectious Diseases Society of America guidelines.

Case report: A middle-aged male with recent IE and aortic valve prosthesis presented to the emergency department with altered mental status and hypoglycemia. He had right basilar lung rales but no heart murmur, leg swelling, or jugular venous distension. He met sepsis criteria with leukocytosis and hypothermia. Computed tomography head was performed due to his altered mental status and revealed a right parietal-occipital hypodense lesion concerning for an abscess with edema and mass effect. Given his history of IE and ill appearance, three blood culture sets were drawn and intravenous antibiotics initiated. The patient was admitted to the hospital with magnetic resonance imaging confirming brain abscess; and neurosurgery performed a craniotomy with brain abscess evacuation. Intravenous antibiotics were continued for four weeks for septic brain emboli from recent IE.

Conclusion: Clinicians should keep a broad differential for altered mental status patients. Sepsis patients should have antimicrobials initiated within one hour. Expedited diagnosis with three sets of blood cultures, echocardiography, and surgical consult should be completed in patients with suspected infective endocarditis for improved patient outcomes. Finally, clinicians should evaluate for septic emboli symptoms such as neurological deficits or respiratory symptoms.