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Infective Endocarditis: a Rare Cause of Acute Coronary Syndrome Javaid Arif Khan, Ziauddin Panwar, Fayyaz Mujtaba and Kashif Shah

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Infective Endocarditis: a Rare Cause of Acute Coronary Syndrome Javaid Arif Khan, Ziauddin Panwar, Fayyaz Mujtaba and Kashif Shah CASE REPORT Infective Endocarditis: A Rare Cause of Acute Coronary Syndrome Javaid Arif Khan, Ziauddin Panwar, Fayyaz Mujtaba and Kashif Shah ABSTRACT This is a case report of a 26 years old female who presented in emergency with sudden onset of chest heaviness and dyspnoea. She had suffered a stroke in the past and was treated with anti-tuberculous medication. Her ECG revealed ST- elevation myocardial infarction and thrombolysis was performed but was unsuccessful. Further workup during in-hospital stay revealed evidence of infective endocarditis and Streptococcus species were isolated. She was started on penicillin and gentamycin with good recovery. This case presented a management problem during initial presentation as there was insufficient data on thrombolysis during such situation. It is also a diagnostic problem as the initial picture was dominated by acute coronary syndrome. There is need to develop consensus based on expert opinion about management in such situations. Key words: Infective endocarditis. Acute coronary syndrome. Management. INTRODUCTION had no risk factors for ischaemic heart disease. She had suffered an ischaemic stroke one year back; was later Infective endocarditis (IE) is associated with a number of diagnosed as tuberculous meningitis and started on anti- complications.1 Peripheral systemic embolism is a tuberculous treatment. common and serious complication of infective endo- carditis linked to migration of vegetations.2 The brain At presentation, she had a temperature of 99.5°F and and spleen are the most common place in endocarditis was well oriented in time, place and person. Her blood involving left side of the heart, while pulmonary pressure was 110/70 mmHg and pulse 110/minute embolism is common in native valve endocarditis and regular. Chest auscultation revealed occasional involving right side of the heart and endocarditis related wheezing, a diastolic murmer at left sternal border and a to pacemaker lead. systolic murmer at the apical area. Chest radiograph was performed on the day of admission, which showed Myocardial infarction is a rare complication and can increased cardiothoracic ratio and clear lung fields. arise due to coronary embolism and external coronary Electrocardiogram was abnormal with ST-segment compression.3 Coronary ischaemia can also be due to a elevation in leads V1 to V6, Q-waves in lead II,III and large vegetation obstructing the coronary ostium or aVF and poor R wave progression (Figure 1). Serum severe aortic regurgitation.4 Surgery on left side of the creatinine kinase (CK-MB) was raised more than eight heart for endocarditis can also lead to coronary emboli times above the normal value and showed decline in and myocardial infarction.5,6 These complication can level at 5th day after myocardial infarction. BUN, pose serious management issues as described in the creatinine and electrolytes were within normal limits. present case report. Complete blood count performed few hours after CASE REPORT admission showed white cell count of 16,000/cubic millimeter and a haemoglobin of 10.5 g%. Transthoracic A 26 years old female presented to the emergency echocardiography performed on next day demonstrated department with sudden onset of chest heaviness and dyspnoea since 3 hours. The pain was central with radiation to both arms. She had no history of such complaints in the past. Systemic review of her history revealed that she had low grade fever since one year, which was associated with fatigue and weakness. She Unit II, National Institute of Cardiovascular Diseases, Karachi. Correspondence: Dr. Javaid Arif Khan, CM-27 and 28, Street Number 25, Model Colony, Karachi. E-mail: [email protected] Received May 12, 2010; accepted November 04, 2011. Figure 1: Electrocardiogram showing antero-lateral myocardial infarction. 248 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4): 248-249 Infective endocarditis: a rare cause of acute coronary syndrome severe aortic regurgitation, mild to moderate mitral myocardial infarction is due to coronary embolism from regurgitation and mobile echogenic masses attached endocarditic valves standard thrombolysis regimes to non-coronary and right coronary cusps and also on should be avoided.8 Although thrombolysis was atrial side of anterior mitral leaflet. Left ventricular performed, no acute complications were encountered as diastolic and systolic dimensions were 64 mm and 39 related to it. mm respectively and ejection fraction was 40% with Another case report showed successful outcome from anterior-inferior wall hypokinesia. Blood culture identified thrombolysis in the setting of acute myocardial infarction Streptococcus species sensitive to chloramphenicol, with infective endocarditis. The case highlighted the penicillin and vancomycin and resistant to erythromycin current lack of definitive data on the optimal acute and ciprofloxacin. Penicillin minimum inhibitory concen- management of such an unusual clinical scenario. tration was 0.06 microgram/ml. During acute presen- Although there is serious concern that thrombolytic tation in ER, treatment for acute coronary syndrome was treatment for myocardial infarction in the setting of given which also include thrombolysis but results were infective endocarditis may be associated with higher risk not satisfactory. The ECG after thrombolysis showed of cerebral haemorrhage, there is little documented only minor resolution of ST-elevation and developed Q- evidence supporting the safety of primary percutaneous waves in the follow-up electrocardiogram. Empirical coronary intervention with these patients.8 treatment was started with benzylpenicillin and gentamycin and the patient responded well clinically and This case report is exceptional because acute also by decrease in total leukocyte count. She was myocardial infarction is a rare presentation of infective treated for 4 weeks. endocarditis and also as it raises concerns regarding lack of data on proper management approach in such DISCUSSION cases. We suggest that there is a need to develop some strategy to treat patients who present with endocarditis Embolism to coronary arteries is a documented and acute coronary syndrome. complication of bacterial endocarditis but it rarely causes acute myocardial infarction. The need for speedily REFERENCES restoring coronary artery blood flow and the little time available for clinical decisions may prevent 1. Mansur AJ, Grinburg M, da Luz PL, Bellotti G. The complications of infective endocarditis: a re-appraisal in the 1980s. Arch Intern diagnosis of endocarditis before any pharmacologic or 1992; 152:2428-32. mechanical thrombolysis can be carried out. In this case Med it was realized late during acute presentation and we 2. Roxan CJ, Weekes AJ. Acute myocardial infarction caused by coronary embolism from infective endocarditis. J Emerg Med 2011; performed pharmacologic thrombolysis although we 40; 50:509-14. Epub 2008 Oct 23. could have attempted mechanical thrombolysis in this 3. Horstkotte D, Folath F, Gutschik E, Lengyel M, Otto A, Pavie A, case. A case report described the first documented et al. Guidelines on prevention, diagnosis and treatment of cases of coronary angioplasty in 2 patients with infective endocarditis executive summary, the task force on acute myocardial infarction caused by bacterial infective endocarditis of Europeon Society of Cardiology. Eur endocarditis, and reviews the literature on coronary Heart J 2004; 25:267-76. artery complications of bacterial endocarditis. The first 4. Herzog CA, Henry TD, Zimmer SD. Bacterial endocarditis patient developed a coronary artery aneurysm and the presenting as acute myocardial infarction: a cautionary note for second experienced a small intracerebral haemorrhage the era of reperfusion. Am J Med 1991; 90:392-7. following reperfusion. It is not a good idea to generalize 5. Beak MJ, Kim HK, Yu CW, Na CY. Mitral valve surgery with from two cases, but we consider that in patients in whom surgical embolectomy for mitral valve endocarditis complicated the endocarditis is the cause of acute myocardial by septic coronary embolism. Eur J Cardiothorac Surg 2008; 33: infarction, the use of conventional strategies for 116-8. Epub 2007 Oct 31. coronary reperfusion should be done cautiously 6. Luther V, Showkathali R, Gamma R. Chest pain with ST because of risk of possible detrimental consequences.7 segment elevation in a patient with prosthetic aortic valve endocarditis: a case report. J Med Case Report 2011; 5:408. There is inadequate information available to guide us 7. Connolly DL, Dardas PS, Crowley JJ, Kenny A, Petch MC. Acute about the best treatment options in patients who present coronary embolism complicating aortic valve endocarditis with such difficult scenarios. A case report of coronary treated with streptokinase and aspirin: a case report. J Heart Valve embolism secondary to aortic valve endocarditis showed Dis 1994; 3:245-6. that it was treated with streptokinase and aspirin. The 8. Chen Z, Ng F, Nageh T. An unusual case of infective endocarditis patient survived but suffered a large myocardial presenting as acute myocardial infarction. Emerg Med J 2007; infarction and a major gastrointestinal bleed. When 24:442-3. lllllOlllll Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4): 248-249 249.
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