Critical Care Medicine-Neurologic Disorders>>>>>Cerebrovascular Diseases
Question 1#

A 49-year-old man with no past medical history is admitted to the medicine service for 2 weeks of intermittent night sweats, myalgia, and progressive headache. Other than febrile, his vital signs are normal at the time of admission. His neurologic examination at the time of admission is normal, and basic laboratory workup is unrevealing. A lumbar puncture is performed with a normal opening pressure, pleocytosis with 41 white blood cells/microL (94% polymorphonuclear cells), 5 red blood cells/microL, glucose 58 mg/dL, and protein 53 mg/dL. There was concern for potential infectious meningitis, so vancomycin, ceftriaxone, and acyclovir were started. One day following the lumbar puncture, the patient had acute onset of marked expressive aphasia and right facial weakness. A head computed tomography (CT) was completed and demonstrated in the figure that follows.

Additional workup was completed to determine the etiology of his stroke, and he was found to have a mobile target on the anterior leaflet of the mitral valve, concerning for endocarditis (shown in the figure below), and the mitral valve has severe mitral valve regurgitation.

What is the next best step in management of the patient’s possible endocarditis?

a. The patient should undergo urgent (within 5 days) mitral valve replacement
b. The patient should undergo urgent (within 5 days) mitral valve repair
c. The patient should undergo delayed (∼4 weeks) mitral valve replacement
d. The patient should undergo delayed (∼4 weeks) mitral vale repair
e. Only antibiotics therapy is needed, and current antibiotics should remain the same

Correct Answer is D

Comment:

Correct Answer: D

The patient meets Duke criteria for possible endocarditis, given he has one major criteria (transthoracic echocardiography [TTE] with new regurgitation and mobile target) and two minor criteria (fever and emboli). The patient has a severe mitral regurgitation, which will require surgical repair. There are mixed criteria for early intervention, but the American Heart Association recommends early intervention if any of the following is observed:

  1. Valve dysfunction causing symptoms or signs of heart failure
  2. Paravalvular extension of infection with development of annular or aortic abscess
  3. Destructive or penetrating lesion causing heart block
  4. Infection from a difficult-to-treat pathogen such as fungal or highly resistant organism
  5. Persistent infection after the start of appropriate antibiotics

This patient does not meet the criteria above, and there is no need to repair his mitral valve urgently. In addition, given his intraparenchymal hemorrhage, undergoing anticoagulation is not an option at this acute time of his presentation. Overall, endocarditis patients with intracerebral hemorrhage are at high risk for clinical worsening during the first month after symptom onset and have a higher mortality than those without (75% vs. 40%).

References:

  1. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994;96:200-209.
  2. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professional from the American Heart Association. Circulation. 2015;132:1435-1486.