An 8‐Year Old Child with Acute Onset of Headache and Decreased Level of Consciousness; an Unusual Presentation of Bacterial Endocarditis

1Texas Tech University Health Sciences Center, Lubbock, TX
2Texas Tech University Health Sciences Center, Lubbock, TX
3Texas Tech University Health Sciences Center, Lubbock, TX
4Texas Tech University Health Sciences Center, Lubbock, TX

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 341

Case Presentation:

This is an 8‐year‐old female with Marfan's syndrome and mitral valve prolapse who had been experiencing daily fevers for 1 week prior to presentation. On the day of admission she had a sudden headache with subsequent depressed neurologic status. She was seen in a regional emergency department where a rapid influenza test was positive for influenza B. Her mental status continued to worsen and on admission she had no response to painful stimuli with decorticate posturing but no purposeful movements. An EEG was performed which showed bilateral occipital slowing, but no seizure activity. CSF studies were negative. She was intubated for airway protection (GCS 6). She was treated with empiric antiviral and antibiotic therapy. MRI of the brain showed cerebellar and brain stem strokes. A hypercoagulable workup was initiated and the patient was anticoagulated with low‐molecular‐weight heparin. An initial transthoracic echocardiogram confirmed mitral valve prolapse of the anterior leaflet, but there were no vegetations noted. The initial blood culture grew Streptococcus mitis. A transesophageal echocardiogram (TEE) revealed an 8 × 4 mm vegetation on the posterior leaflet of the mitral valve. Evaluation for additional systemic septic emboli including renal ultrasound and lower‐extremity Doppler ultrasounds were all normal. Patient was treated with ceftriaxone for an extended course. Her repeat TEE showed growth of the vegetation to 18 mm although patient had no fevers and subsequent blood cultures were all negative. The vegetation was surgically removed. The patient required extensive inpatient rehabilitation after discharge from the tertiary‐care children's hospital.

Discussion:

Septic emboli are known complications of infective endocarditis. Emboli causing stroke have often been reported in the adult literature but are not frequently described in the pediatric age group. Neurological complications reportedly occur in 40%–50% of patients with left‐sided infective endocarditis; however, native valve endocarditis in the pediatric population is uncommon. Most reports in the literature of septic emboli complicating infectious endocarditis implicate Staphylococcus aureus as the causative organism. This patient had recently lost some baby teeth, which may have been related to the finding of Streptococcus mitis as the causative organism.

Conclusions:

This case highlights stroke as a cause of altered mental status and as a complication of infective endocarditis in the pediatric population. The purpose of reporting this case is to raise the index of suspicion for stroke due to septic emboli in pediatric patients with abnormal native valves and raise awareness for the need of more literature on this topic in the pediatric age group.

To cite this abstract:

Pomeroy L, Pomeroy B, Thompson A, Johnson L. An 8‐Year Old Child with Acute Onset of Headache and Decreased Level of Consciousness; an Unusual Presentation of Bacterial Endocarditis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 341. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/an-8year-old-child-with-acute-onset-of-headache-and-decreased-level-of-consciousness-an-unusual-presentation-of-bacterial-endocarditis/. Accessed May 26, 2019.

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