A Classic Presentation of Infective Endocarditis

Introduction: Advances in modern medicine have enabled early detection of infective diagnosis through blood cultures and echocardiography, which have been standardized by the widely accepted Modified Duke Criteria and have enabled rapid administration of antibiotics. As a consequence, the well-discussed and often variable clinical findings have become less common and have relegated to minor criteria in diagnosis. Fever is the single most common presenting symptom, whereas more specific signs such as petechiae may be seen in only 20-40% of patients. Even more rare are the pathognomonic Janeway lesions, Roth spots, and Osler nodes. Here we present a case in which early diagnosis was established through minor criteria manifest upon physical exam, and we highlight the timely insight provided from physical exam. Case: A 29-year-old man was admitted to the hospital for altered mental status, fever, vomiting, diarrhea, and vertigo. His past medical history included IV drug abuse, thrombotic thrombocytopenia, Hepatitis C, and seizures. Upon admission, his encephalopathy progressed rapidly, and he was mechanically ventilated and started on hemodialysis. Blood cultures grew Methicillin sensitive Staphylococcus aureus and Elizabethkingia meningosepticum and susceptibilities were attained. Echocardiography showed 3.1 cm vegetation on the aortic valve. By the Modified Duke Criteria, the diagnosis of infective endocarditis was confirmed. Discussion: The increasing incidence of complex infective endocarditis—including polymicrobial infection as well as the increasing resistance to antibiotic therapy—poses challenges to the rapid assessment and treatment necessary to mitigate the multi-organ involvement and the devastating consequences of septic emboli. Developments in medical technology have expedited both the diagnosis and treatment of infective endocarditis, which has subsequently decreased the extent and frequency of classical signs. Nonetheless, this case illustrates the unavoidable vitality of the physical exam, because this patient’s quick and clear presentation enabled diagnosis solely through physical exam. Empiric antibiotic treatment was started promptly and subsequently adjusted based on culture and susceptibilities