A 29‐year‐old woman with a medical history of “heart murmur” and remote anxiety diagnosis presented to the ER with a 10‐day history of fever/chills (103°F–104°F), fatigue, and shortness of breath. The patient denied cough, nausea, vomiting, diarrhea, abdominal pain, chest pain, IV drug use, skin lesions, or travel. She reported a 1‐year history of gait imbalance with a recent negative outpatient workup, including a brain MRI, Lyme titers, and LP. The patient had a recent dental procedure without antibiotics. The PE was significant for 3/6 holosystolic murmur. She was released from the ER but was recalled after the blood cultures grew GPC in pairs. On revisit, her vitals were stable without fever. Her physical examination was again positive for a murmur, clear lungs, and a benign abdominal exam. The chemistry panel, WBC, and platelets were normal. She had a normocytic hemoglobin of 9.9 and an erythrocyte sedimentation rate of 75. The chest x‐ray was clear. The patient was admitted for presumptive SBE and received IV vancomycin and ceftriaxone. On day 1, a transesophageal electrocardiogram revealed a normal ejection fraction, a bicuspid aortic valve with thick vegetations, a periaortic abscess, and severe aortic insufficiency. The blood cultures grew Enterococcus faecium. The patient had no stigmata of septic emboli. Because of the abscess and aortic insufficiency, she underwent surgery, receiving a bioprosthetic aortic valve and a root enlargement. On hospital day 14, the patient was sent home with a PICC and 6 weeks of IV ampicillin. Two months status post surgery, the patient continues to improve and has returned to normal activities.
Bicuspid aortic valve has a prevalence of 1%–2%, and IE complicates presentation in 7%–25% of cases. It presents in the 4th and 5th decades of life with a male predominance (>70%). Subacute native valve endocarditis (NVE) affects only abnormal valves. Its course, even without treatment, is more indolent than the acute form, and may extend over months. Enterococci or α‐hemolytic streptococci in the setting of structural valve disease are the principal causative agents. Bicuspid aortic valve endocarditis represents 12% of NVE endocarditis. The most common presenting symptoms are fever (74%), malaise (60%), and murmur (50%). The treatment includes antibiotics and possibly surgery. Operative indications include CHF, severe AI, vegetations, hemodynamic instability, and systemic embolization. In a retrospective study of NVE patients, those with bicuspid endocarditis had a higher rate of surgical treatment (90% vs. 70%). Recent evidence demonstrates that earlier surgical intervention, without evidence of embolic spread or CV compromise, can significantly reduce in‐hospital mortality and subsequent embolic events.
Diagnostic error may have contributed to the patient's delay in diagnosis. She was seen 1‐day prior to admission with a fever and murmur, yet was discharged. Further questioning revealed a missed history of a congenital heart defect and an echo at age 11. Likewise, weeks prior, MDs also pursued testing for less likley diagnoses, for example,MS, psych. In patients with fever, a murmur or (+) BE risks the differential diagnosis must include infective endocarditis.
To cite this abstract:Takhalov Y, Flansbaum B. An Indolent Case of Av Endocarditis: Heuristics and Mindfulness Over Matter. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 331. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/an-indolent-case-of-av-endocarditis-heuristics-and-mindfulness-over-matter/. Accessed November 11, 2019.