A 76-year-old man presents to the ED with a 2-week history of fever, chills, poor appetite, and weight loss. He had a bovine aortic valve replacement 5 years previously for severe aortic stenosis. He was pyrexial. Admission bloods revealed a white cell count of 16.0 × 109 /L and C-reactive protein (CRP) 120 mg/dL. TOE was performed the next day.
What is the abnormality shown on the echocardiogram?
The transoesophageal echocardiogram shows the long-axis view which includes the aortic and mitral valves. The translucent area above the aortic valve replacement is an aortic root abscess. There is severe paravalvular aoric regurgitation. In addition colour flow is seen between the aortic root and the left atrium (superior to the anterior mitral valve leaflet) which represents a perforation of the anterior mitral valve leaflet/annulus attachment.
A 59-year-old man with a bicuspid aortic valve and a background of benign prostatic hypertrophy presents with a 1-week history of fever and lethargy. He had been treated by his GP with oral antibiotics for a urinary tract infection (UTI) a week prior to admission. On examination, an ejection systolic murmur was audible on auscultation. As part of his initial investigations routine bloods and blood and urine cultures were taken. His urine culture sent by his GP has grown Escherichia coli. The admitting team suspects endocarditis.
What is the next step of management?
According to ESC Guidelines 2009, TTE is the first-line imaging modality in cases of suspected endocarditis. TOE should be done if suspicion of IE is high and TTE is normal or inconclusive.
Which one of the following is a predictor of poor outcome in patients with infective endocarditis?
The in-hospital mortality rate of patients with IE varies from 9.6% to 26%, but differs considerably from patient to patient. Prognosis in IE is influenced by four main factors: patient characteristics, the presence or absence of cardiac and non-cardiac complications, the infecting organism, and echocardiographic findings. The risk of patients with left-sided IE has been formally assessed according to these variables. Patients with heart failure, periannular complications, and/or Staphylococcus aureus infection are at highest risk of death and need for surgery in the active phase of the disease. When three of these factors are present, the risk reaches 79%. A high degree of comorbidity, insulin-dependent diabetes, depressed left ventricular function, and the presence of stroke are also predictors of poor in-hospital outcome. In those patients who need urgent surgery, persistent infection and renal failure are predictors of mortality. Predictably, patients with an indication for surgery who cannot proceed owing to prohibitive surgical risk have the worst prognosis.
An 80-year-old woman with a background of moderate aortic stenosis presents with a 2-week history of fatigue, weight loss, and night sweats. She has a history of nausea and altered bowel habit. Bloods revealed Hb 9.9 g/dL, white cell count 16.0 × 109 /L, and CRP 187 mg/L. Blood cultures were taken on admission and she was commenced on empirical antibiotics. TTE demonstrated an aortic valve vegetation.
The presence of which one of the following organisms would prompt gastrointestinal investigations?
Group D streptococci (Streptococcus bovis) are an increasingly frequent cause of IE, especially in the elderly, and are associated with colonic disease.
A 71 year old man presents 10 months after aortic valve replacement with fatigue, weight loss, and fever. Six weeks previously he had had treatment for a dental abscess. Whilst results from blood culture were awaited, a transthoracic echocardiogram revealed an aortic valve vegetation.
Which of the following is the most appropriate next step?
First-line empirical antibiotic treatment for endocarditis which occurs <12 months post-surgery is a combination of vancomycin, gentamycin, and rifampicin.
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