Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. eadForde Gerard octogenarian an in endocarditis of presentation Atypical isddet t ihfeunyo etceblsto 3.Acs fari av netv noadtsin with endocarditis atypically infective presented valve who aortic (AS) of stenosis case aortic severe A of [3]. history embolisation background septic a proposed of with been lady frequency also 87-year-old high (NVS), has an its streptococcus and to variant (IE) due nutritionally endocarditis missed infective a [2]. streptococcal as endocarditis of Classified culture-negative 6% in to pathogen up possible for a accounts as It [1]. tract defectiva, with A. patients older in essential is Introduction: therapy antimicrobial targeted defectiva of A. commencement non and following diagnosis adults Prompt older unwell non-specifically in performed tions. be should cultures Blood Message Clinical Key presentation atypical Galway Keywords: Hospital, University Pathology, of Department Galway *** Hospital, University Biochemistry, Clinical of and **Department Galway Shatwan*** Hospital, University Ramadan Microbiology, Galway of Okiro, Hospital, *Department University Julie Medicine, Shea**, Geriatric of O Department M Paula Mulkerrin Lucey*, C Eamon Mary Forde, Gerard of presentation Atypical that highlights findings. case This sepsis. defectiva) (A defectiva Abiotrophia Abstract 2020 11, September 2 1 Mulkerin Eamon alaUiest optlGroup Hospital University Saolta Galway Hospital University .defectiva A. IE. sa raimwihi ato h omlflr fteitsia rc,oa aiyadurogenital and cavity oral tract, intestinal the of flora normal the of part is which organism an is netv endocarditis, infective 1 ayLucey Mary , a eascae ihahg rprino utr-eaieIE. culture-negative of proportion high a with associated be may 2 borpi defectiva Abiotrophia defectiva A aecueo atra netv noadtsI)otnpeet ihprxaadflorid and pyrexia with presents often endocarditis(IE) infective bacterial of cause rare a , 1 al Shea O Paula , borpi defectiva Abiotrophia borpi defectiva Abiotrophia Ecnpeetnnseiclyi le ri ainswtotcasclclinical classical without patients frail older in non-specifically present can IE 1 aaa Shatwan Ramadan , 1 netv noadtsi noctogenarian an in endocarditis infective urtoal-ain tetcci le patients, older Streptococci, nutritionally-variant , A.defectiva a aedvsaigipiain if implications devastating have can infective 1 ui Okiro Julie , -s eicpresenta- pecific 1 and , Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. tntc(aiu rdet7mH)ari av iheiec fari eugtto Fgr 3A). (Figure regurgitation aortic of evidence by on advised with vegetation were valve as a tests aortic of (IE), of sensitivity suggestive 74mmHg) endocarditis diagnosis while echo-density gradient infective empirically A mobile (maximum started as large was stenotic treat a daily revealed a to once echocardiogram decision Transthoracic grams the 2 pending. prompted Ceftriaxone scan Microbiology. CT Clinical on infarcts splenic of tachycardia combination transfusion delirium, of The RCC hypoactive identification of mild units the consciousness, further with fluctuating pyrexia. 2 by Concurrently for low-grade requirement evidenced and consistent with sepsis, disease. PR appearances clinical diverticular bleeding revealed developed further and This and had bleeding patient 2) loss. further the (Figure weight infarcts, had subacute infarcts splenic of then splenic gastroin- background ongoing multiple investigate but a colonoscopy. to with improvement against and/or performed were preparation loss clinical pelvis bowel and blood for with abdomen testinal(GI) the unfit of hours was scans RCC She (CT) 48 tomography and stable. Computed next haemodynamically haemoglobin the remaining in although over PR, fall reveal stabilised not associated patient did with which The admission, PR of ulceration. five bleeding or day bleeding of on active/recent oesophagogastroduodenoscopy any episodes an underwent two She had transfusion. patient the Thereafter, 108 of 1. 200 Table creatinine 10 - serum x 10 mmol/L), 320 range 8.2 of – count 2.9 platelet μ range fl), (reference 96 mmol/L - 10 8.6 84 10 x range x 11.6 Gram- 400 (reference of with - (WBC) fl 10 count hours 85.0 cell x 14 volume blood 10 at corpuscular as white identified - positive and included: 4 agar flagged admission chocolate on range cultures on values cultured blood laboratory later which Other admission chains, 15 1) and of - pairs 12 in bottles (RCC). cocci range aerobic positive concentrate (reference cell and 7.7g/dL red anaerobic of had of haemoglobin Both unit she acute a one suspected ED, with of for admission, history the protocol commenced transfusion on the recent In was necessitating anaemic of daily There any g/dl), part was times palpation. investigations, denied three lady cause) on 1.2g etc. This patient clinical co-amoxiclav tenderness obvious lesions diverticulitis. (IV) the (without Intravenous abdominal janeway adult and generalised service. unwell aortic haemhorrages, C our her mild mixed within splinter of 36.7degrees and part with as of as pallor consistent cultures such was temperature murmur blood IE There a diastolic of early with rigors. stigmata and pyrexia of the systolic recorded of ejection no recent an none heart was any and minute, and without 116/50mmHg per of dyspnoea disease pressure exertional beats valve blood stable 82 a revealed had of examination and physical rate Initial pain abdominal symptoms. in significant deterioration any history. denied dys- smoking patient radiotherapy), pack-year The with 80 months definitively an five (treated and intervention carcinoma hypertension coronary stenosis. cell tremor, percutaneous aortic squamous severe tonic with known anal IHD with for disease, pre-admission significant decline diverticular 8) previously, otherwise functional was score: and history Scale months Frailty medical three (Clinical Past over frail was bleeding kg octogenarian of 5 This history of three-day loss a weight period. with subacute five-week (ED) a malaise, department over general emergency with the associated to PR self-presented lady 87-year-old images. An to radiographic consent her informed as written well gave History: patient as Case The data laboratory described. and is clinical decline functional her and reporting (PR) rectum per bleeding o/) eu lui 1gL(eeec ag 9–5 /) n eu ertn11 gm (reference ng/mL 1015 ferritin serum and g/L), 51 – 39 range (reference g/L 31 albumin serum mol/L), 9 L,srmCratv rti f6 gL(eeec ag gL,bodue irgnof nitrogen urea blood mg/L), 5 – 0 range (reference mg/L 62 of protein C-reactive serum /L), μ .defectiva A. o/) h amtlgcladbohmclprmtr fteptetaetbltdin tabulated are patient the of parameters biochemical and haematological The mol/L). 9 L,aslt etohlcuto .4x10 x 9.24 of count neutrophil absolute /L), .defectiva A. Ewsmd.TeIfciu ies emwscnutdadintravenous and consulted was team Disease Infectious The made. was IE atrei ihogigprxa nw otcmru n apparent and murmur aortic known pyrexia, ongoing with bacteraemia 2 9 L(eeec ag 10 x 7 - 2 range (reference /L μ o/ rfrnerne4 90 – 49 range (reference mol/L 9 L(eeec ag 150 range (reference /L .defectiva A. 9 L(reference /L 9 L,mean /L), (Figure Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. ahgn nteciia aoaoyb rvdn ai,acrt n oteetv en fbacterial of means effective cost and accurate rapid, a desorption providing routine laser by these by assisted identify laboratory to culturing matrix [1]. possible clinical as difficulty increasingly endocarditis the it such negative and made in culture identification has morphology spectrometry all of pathogens mass colony in methods (MALDI-TOF) pathogen flight stains, molecular of potential Gram ionization-time of a introduction in blood considered on the variation be grow However, must the to NVS pyridoxal to or methods, to L-cysteine Due laboratory of addition al. the [1,7]. require et agar characteristically NVS Bouvet satellite nature, by the in Fastidious 1991 of of growth in number the speciated a supplementing of further reclassification be was to named NVS noted larger sequencing, to were [1]. adjacent colonies growing NVS larger streptococci defectivus termed satellite The of later series media. a bacteria, isolated agar first on Hirsch and bacteria Fenkel 1961, possible In is humans. It haemorrhagic haemorrhoids. recurrent defectiva of being context A. bleeding the in PR translocation penicillin-based of bowel major of to evidence intermittent secondary initiation confirmed of was episodes. bacteraemia the examination cause of Following Post-mortem likely source The IE. the the that valve sterile. with heart. were aortic IE the cultures valve of subsequently aortic blood diagnosis and a repeat abdomen therapy to the antimicrobial lead of which imaging investigations following sepsis further the and of prompting evidence decline had and antibiotics of patient PR functional the oral confirmation bleeding While PR, further to had sepsis. bleeding switch she associated co-amoxiclav, of a with IV diverticulitis symptoms on biochemical acute improvement was with and clinical diagnosis initial haematological associated working initial limited reactants The relatively phase anaemia. with acute non-specifically, of presented derangement octogenarian the frail was This by atheroma represented coronary changes triple hypertensive severe Discussion: to of secondary death. evidence microscop- arrhythmia of with and cause cardiac likely grossly surfaces Lethal most examination cortical detailed vessels. granular on blood showed infarction thickened of Kidneys evidence No no (Figure ically. showed haemorrhoids spleen internal disease. upper of the diverticular the evidence Unexpectedly, in revealed mild which found demonstrated area focus which anal bleeding the bowel no within 5). was large tumour the There recurrent within or changes of atheroma. bowel ischaemic evidence acute calcified small of severe evidence tract, showed no aorta gastrointestinal(GI) was entire occlusion There 90% for and The 4). with 3B-D) (Figure Not further heart. associated (Figure vessels stents declared microscopically necessitating coronary aortic coronary and three severe being to Hb the grossly confirmed adjacent and, involving which leaflets in atherosclerosis valve post-mortem coronary unresponsive drop the a critical and of had widespread a vegetation severe She pulseless with and ward. found calcification the PR was with on bleeding stenosis peacefully she died day, further she that had Resuscitation, Active Later patient the transfusion. 15, RCC day on pre- Unfortunately, significant was and therapy frailty antimicrobial her to given response . replacement biochemical valve and for clinical candidate initial a an noted. be However, to co-morbidities. not morbid deemed was with patient associated revealed milligrams frequently brain The complication 50 the a of gentamicin parenchyma, scan brain CT and the A hours in defectiva protocol. emboli A. four per septic as of every levels evidence serum gram radiographic gentamicin no 1 of monitoring amoxicillin with daily, to times three switched was therapy antimicrobial and noadts[4]. endocarditis sa V osdrdpr ftenra oao h rlcvt,G n rgntltatin tract urogenital and GI cavity, oral the of flora normal the of part considered NVS an is tetccu adjacens Streptococcus .defectiva A. Abiotrophia atrei ihkonA n vdneo oeta moiainprompted embolisation potential of evidence and AS known with bacteraemia Abiotrophia 6.Frhrsqecn are u yClise l ruh bu the about brought al. et Collins by out carried sequencing Further [6]. 5.I 95anwgnso V a dnie hog 6 rRNA 16S through identified was NVS of genus new a 1995 In [5]. tan n20 n the and 2000 in strains 3 Granulicatella eu a ae [7]. named was genus Streptococcus Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. ihnnra aaeesadhrciia ttswsntcnitn ihetniebwlicama Unfor- ischaemia. bowel extensive always with was consistent level not colonic was lactate of status serum the possibility clinical patient’s during the her the PR and However, raised bleeding parameters Persistent emboli, ischaemia. normal likely. splenic bowel within be septic associated apparent to with thought of embolisation was background septic sepsis a of against source admission intra-abdominal patient’s an case this likely In is of it literature. prevalence organism, the the with that in this often conceivable reported of sepsis is identification of it signs Moreover, and florid culture [16]. manifes- more with unusual with difficulty an presents classically the represents that which Given symptoms organism non-specific rare consequences. with a devastating patient with valves. infection older of defective this of tation of structurally Cases presentation or atypical non-native [15]. The pyrexia of failure with presence heart presentations the to and reference refer and/or ?need shock literature patients septic the immunocompromised in of of evaluated involve age features cases the over endocarditis with patients NVS in associated embolic age-group of observed [19,26]. this of majority damage case of vast endothelial this presence reports valvular The in in case of the outcomes as other rates However despite comorbidities high with severe the consistent successful [13]. of or is generally reflection 60, patients case a this is old often of very intervention is mortality to and surgical sudden children The as 21–23]. young [14]. [15, better from complications much peritonitis groups and are age to endophthalmitis all children independent to affects is osteomyelitis pathogen which vertebral This NVS of of endocarditis, reports virulence quadruple-valve hundred-case and from one pathogenicity such over patients, high are older the There inhibitory as in minimum well comorbidities as with threatening clinical sensitivity. case life ceftriaxone the antimicrobial this organism of and its this in presence and penicillin of deemed IHD frequent nephrotoxicity sensitivity severe is both the the as of person reflecting to Despite the poor, risk sensitive respectively. if was 0.5mg/L was the and or outcome report mg/L due infection 0.125 case of is setting of this focus concentrations the This extra-cardiac in in British an gentamicin isolate the surgery. is with However The ceftriaxone there for [12]. of if candidate treatment use Cardiology or of a the of endocarditis weeks advise valve Society 2 not prosthetic and European do first of ceftriaxone The Chemotherapy the benzylpenicillin, Antimicrobial often for work-up. including of can aminoglycoside options Society for testing an treatment laboratories susceptibility with antimicrobial of reference combined of vancomycin results IE to number NVS and sent a of vary are recommend setting treatment (ESC) isolates the on in if guidelines treatment delayed as antimicrobial be straightforward, of of Choice not were isolates often [11]. vancomycin is 53% the and remaining of meropenem of to the 50% third susceptible and whereas One resistant observed NVS. were was of 14% number penicillin, general of a to 18.9% In susceptible of were sensitivity. patterns study intermediate susceptibility the of in investigation been examined extensive have of which an resistance phenomenon out embolic that for associated account suggests may the which Evidence produce fibronectin and with valves bind [13,15,16] heart to described to ability the previously adhere the and and to base exopolysaccharide propensity data of its production a [1]. the to endocarditis as referenced such streptococcal to cross all attributed is of been has 5-6% analysis for sample account where NVS analysed detector [8]. and identified the mass and to to matched according flight’ is separated of bacteria are ‘time isolates their samples, of by ionization Following [9–11]. identification .defectiva A. .defectiva A. a eascae ihahge rprino utr-eaieI hnpeiul reported previously than IE culture-negative of proportion higher a with associated be may eitn opncli.N eitneof resistance No penicillin. to resistant < %o l atra noadts[] h raimhsanme fvrlnefactors virulence of number a has organism The [9]. endocarditis bacterial all of 1% .adiacens G. .defectiva A. .defectiva A. defectiva A sltswr eitn ocftxm.Alioae eefully were isolates All cefotaxime. to resistant were isolates a on ob oerssatthan resistant more be to found was opncli sicesn 1] let ta.carried al. et Alberti [10]. increasing is penicillin to 4 .defectiva A. epsae neto nteltrtr.Teerange These literature. the in infection deep-seated .defectiva A. .defectiva A. neto nodrptet shge than higher is patients older in infection lsrdu difficile Clostridium srrl utrdscesul and successfully cultured rarely is otidgnrto cephalosporins generation third to .defectiva A. Erpre often reported IE .adiacens G. neto [12]. infection with Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. fGauiael e.nv,Gauiael daescm.nv,Gauiael lgn ob o.and nov. comb. elegans Granulicatella nov., comb. adiacens Granulicatella nov., gen. respectively. Granulicatella Lawson, nov., P.A. of and comb. M.D. defectiva Collins, Abiotrophia 1995. 7. and Microbiology, Evolutionary nov. and Systematic comb. of adiacens Journal Abiotrophia as al., nov. et Y., Kawamura, 6. 1991. Microbiology, Evolutionary adjacens. Grimont, Streptococcus and and P. Systematic defectivus Streptococcus and of of patterns Grimont, restriction F. gene rRNA A., Bouvet, 5. al., 2013. et A., Bajaj, 4. 1987. diseases, infectious Nelson, of K.E. Reviews and D.S. Stein, 3. al., species. et L., Senn, 2. K.L., Ruoff, 1. disclose. to interest References of conflicts no have authors The Statement: Interest of Conflict (equal) Mulkerrin: C Eamon Okiro: Julie Shatwan: Ramadan Shea: O M Paula Lucey: Mary (equal) Forde: patients. older Gerard in especially non-specific and, in Contribution: variable essential Author highly is are therapy symptoms antimicrobial presenting targeted since complications, of with commencement patients and and arrythmia. older isolation fatal diagnosis was in pathogen IHD was accurate resulting diagnosis, severe and probably of Prompt established antibiotics death, pre-existing importance IV of Her suspected cause to the population. attributable or responded emphasising encountered likely known tests, frequently the status, invasive with this for functional in blood especially unfit treatment performing baseline definitive imaging, and of her frail importance cardiac towards the with albeit and highlights patient, associated returning case adults The often This older complications [17]. disease. unwell cases devastating valvular of non-specifically have third diverticulitis. can in bacteraemia. one or of and to cultures source up tumour clinically likely in ischaemia, most identified embolisation the bowel rarely septic was of is tract GI pathogen evidence lower haemorrhoids This the pathological from post-mortem, no translocation at with bacterial However, that PR. source, suggests bleeding colonic actual This for and/or likely causes diverticulitis clinical the acute plausible but were colonoscopy most or the sigmoidoscopy were proctoscopy, carcinoma for unfit was she tunately, 4 26:p 2. p. (276): M netosDsae,2006. Diseases, Infectious BMC ocpulzto scnay;wiig–rve n dtn (equal) editing and review – writing (secondary); Conceptualization urtoal ain streptococci. variant Nutritionally ocpulzto scnay;wiig–oiia rf (secondary) draft original – writing (secondary); Conceptualization ocpulzto la) rtn rgnldat(ed;wiig–rve n editing and review – writing (lead); draft original – writing (lead); Conceptualization losra n noaclrifcin u oAitohadfciaadGranulicatella and defectiva Abiotrophia to due infections endovascular and Bloodstream otcvleedcrii yarr raim borpi defectiva. Abiotrophia organism: rare a by endocarditis valve Aortic .defectiva A. aacrto la) omlaayi (lead) analysis formal (lead); curation Data rtn rgnldat(eodr) eore (lead) resources (secondary); draft original – Writing rnfro tetccu daesadSrpoocsdfciu oAitohagen. Abiotrophia to defectivus Streptococcus and adjacens Streptococcus of Transfer uevso la) octaiain(eodr) rtn eiwadediting and review – writing (secondary); concetualization (lead); Supervision noadtsdet urtoal ecetsrpooc:teaetcdilemma. therapeutic streptococci: deficient nutritionally to due Endocarditis E hsi atclryiprati re opeetptnilyfatal potentially prevent to order in important particularly is This IE. h eu borpi Kwmr ta. sntmnpyei:proposal monophyletic: not is al.) et (Kawamura Abiotrophia genus The 9 5:p 908-916. p. (5): 6 1:p 1-6. p. (1): nrseisvrain nntiinlyvratstreptococci: variant nutritionally in variations Intraspecies lnclmcoilg eiw,1991. reviews, microbiology Clinical 41 5 4:p 483-486. p. (4): 45 4:p 798-803. p. (4): lnEpCardiolog, Exp Clin J nentoa Journal International 4 2:p 184-190. p. (2): International Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. al :Ruieheaooia n iceia netgtosfo diso ody1 fhospitalisation of 15 day to admission from investigations biochemical and haematological Routine 1: Table al., review. et S., Giuliano, 17. cases. 5 L´opez, of J. Report Ladr´on, and R. Garc´ıa-Granja, P.E., 16. al., et J.A., Pinkney, 15. al., children. et in S.H., Song, 2011. 14. Sciences, Medical the the of by Journal al., Endorsed American et Society D.D., (ESC). International Kohok, Cardiology Cancer. Diagnosis, the 13. and of and Prevention, Infection (ESCMID) Society the for Diseases European on (ISC) Infectious Force Chemotherapy the and Task of Microbiology of Clinical the Endocarditis of 2009): Society Infective European version of (new Treatment endocarditis and infective al., of et treatment and G., Habib, 12. 1411-1420. elegans. p. Granulicatella Humphries, and R.M. adiacens, and Hindler, Granulicatella J.A. M.O., Alberti, 11. Washington, J.A. and defectiva. Abiotrophia Procop, and G.W. M.J., Tuohy, 10. streptococci. al., dependent et R.B., Roberts, 9. Butler-Wu, 2013. medicine, S.M. laboratory and in T.C. Clinics Dingle, 8. 2000. nov. comb. balaenopterae Granulicatella 50 ess 2012. sepsis, 1:p 365-369. p. (1): neto,2020. Infection, eiiaciia 2019. clinica, Medicina 1 eiw fifciu iess 1979. diseases, infectious of Reviews .2. p. : borpi eetv sacueo netv noadtswt moi complications embolic with endocarditis infective of cause a as defectiva Abiotrophia noadtscue yntiinlyvratsrpooc:acs eotadliterature and report case a streptococci: variant nutritionally by caused Endocarditis S omte o rcieGieie.Gieie ntepeeto,diagnosis, prevention, the on Guidelines Guidelines. Practice for Committee ESC uaahodhmrhg naptetwt borpi eetv endocarditis. defectiva Abiotrophia with patient a in hemorrhage Subarachnoid iiassrpoocledcrii:terl fvrosseis nldn pyridoxal- including species, various of role the endocarditis: streptococcal Viridans borpi eetv endocarditis. defectiva Abiotrophia igotcmcoilg n netosdsae 2000. disease, infectious and microbiology Diagnostic 33 AD-O assetoer o irogns identification. microorganism for spectrometry mass MALDI-TOF 3:p 589-609. p. (3): nentoa ora fsseai n vltoaymicrobiology, evolutionary and systematic of journal International 152 5:p 201-202. p. (5): 341 u er ,2009. J, Heart Eur urtoal ain tetcciifcieendocarditis: infective streptococci variant Nutritionally 6 niirba gnsadceohrp,2016. chemotherapy, and agents Antimicrobial 2:p 157-159. p. (2): niirba ucpiiiiso borpi defectiva, Abiotrophia of susceptibilities Antimicrobial niirba ucpiiiyo borpi adiacens Abiotrophia of susceptibility Antimicrobial aeRprs 2014. Reports, Case 1 6:p 955-966. p. (6): 30 1) .2369-2413. p. (19): 38 2014 3:p 189-191. p. (3): .bcr2014207361. p. : 60 The (3): Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. (mmol/L) Urea Serum (mg/L) protein reactive C- (10ˆ9/L) count Platelet (fL) volume cular corpus- Mean (g/dL) Haemoglobin (10ˆ9/L) Count Neutrophil 10ˆ9/L) ( Count Cell White (Unitage) parameter Laboratory 4-9 58 68 48 83 84 84 85 86 2.9-8.2 < 84 400 - 150 85 96 - 84 15 - 12 7 - 2 10 - 4 15 Day 10 Day 8 Day 7 Day 5 Day 2 Day 1 Day Interval Reference 5 2 6 2 3 1 9 231 292 9.2 312 8.6 338 8.2 327 8.6 9.0 263 9.7 320 8.5 7.6 7.7 9.2 11.6 RCC of unit 1 Hb: Low Admission 62 / . . . . 2.7 3.8 4.1 5.2 4.3 n/r 8.6 9.8 * n/r 5d for tds 1.2g clav Coamoxi- IV 7 6.9 23. 332. 19.6 25.7 33.3 37.8 52 ulceration bleeding/ recent active/ No OGD . . 7.6 8.2 8.8 9.9 10.6 overnight given RCC of 1unit PR: bleeding additional an suffered patient the afternoon the During disease diverticula & infarcts splenic multiple Revealed CTAP RCC of unit 1 . 8.9 9.2 0gtds 50mg Gentamicin & 4h every 1g cillin *Amoxi- 16:30h @ vegetation for suggestive density echo large a Revealed TTE 14:00h @ 2g/d Ceftriaxone IV to switched clav Coamoxi- Oral @08:00h 6.9 nPeace) in (Rest dead declared sive, unrespon- Pulse-les, RCC 1unit PR bleeding Further Posted on Authorea 11 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159986080.06573835 — This a preprint and has not been peer reviewed. Data may be preliminary. endocarditis-in-an-octogenarian users/356385/articles/479261-atypical-presentation-of-abiotrophia-defectiva-infective- Pathology_figures_Abiotrophia_defectiva_case_report.docx values abnormal file = Hosted bold in echocardiogram transthoracic Data requested, TTE: not pelvis, and n/r: Oesophago-Gastro-Duodenoscopy, abdomen OGD: the hour, of tomography h: intravenous, Computed day, IV: CTAP: treatment, d: antibiotic daily, of times Commencement three *: tds: concentrate, cell red RCC: Haemoglobin, Hb: (mmol/L) Lactate Plasma (ng/mL) Ferritin Serum (g/L) min Albu- Serum ( nine Creati- Serum (Unitage) parameter Laboratory μ mol/L) .-. / / rn . . n/r 0.8 0.8 nr nr 15 Day n/r 10 Day n/r 8 Day 0.6-1.4 7 Day 200 - 10 5 Day 51 - 39 2 Day 1 90 Day - 49 Interval Reference 1015 31 108 / / / / / n/r n/r 58 n/r 58 n/r 61 n/r 59 n/r 60 n/r n/r 8 23 02 23 27 30 32 32 vial at available https://authorea.com/