MEDICAL PRACTICE J Am Board Fam Pract: first published as on 1 November 2001. Downloaded from The Diagnostic Challenge of Infective Endocarditis: Cutaneous Vasculitis Leading to the Diagnosis of Infective Endocarditis Tracey Conti, MD, and Beth Barnet, MD Background: Signs and symptoms of infectious endocarditis are protean. They result from destruction of cardiac endothelium, metastatic embolization, hematogenous seeding, and immune complex deposi- tion. Embolic manifestations of infectious endocarditis can mimic several other pathologic conditions and make the diagnosis of infectious endocarditis difficult. Methods: We describe a case of cutaneous vasculitis leading to the diagnosis of infectious endocardi- tis. A review of the literature highlights the variable clinical presentations and key diagnostic strategies in the evaluation of infectious endocarditis. Results and Conclusion: Infective endocarditis has protean clinical symptoms and signs and can be a challenging diagnosis. Being alert to the condition is crucial, and where a high clinical probability exists despite a negative transthoracic echocardiogram, diagnostic evaluation with transesophageal echocardiograph is required. (J Am Board Fam Pract 2001;14:451–6.) Infective endocarditis, characterized by microbial the key words “infective endocarditis,” “vasculitis,” infection of the endothelial surface of the heart, can and “diagnosis.” Findings highlight the variable have numerous symptoms and signs. Typically they clinical presentations and key diagnostic strategies include fever, chills, a new or changing heart mur- in the evaluation of infectious endocarditis. http://www.jabfm.org/ mur, and bacteremia. Infective endocarditis can ap- pear in an atypical manner and pose in a diagnostic Case Report challenge. In such cases, initial signs and symptoms A 64-year-old woman came to the emergency de- might be those from a complication, such as pneu- partment with a complaint of weakness and confu- monia, meningitis, congestive heart failure, osteo- sion. Her medical history was notable for diabetes myelitis, septic arthritis, glomerulonephritis, en- mellitus, hypertension, chronic renal failure for on 23 September 2021 by guest. Protected copyright. dophthalmitis, splenic infarction, or vasculitis. The which she was receiving hemodialysis, and a remote differential diagnosis of a bacteremic patient with history of breast cancer. She had a history of mild- one of these conditions should include infective moderate left ventricular dysfunction but no valvu- endocarditis. Delays in diagnosis and treatment in- lar heart disease. On review of systems the patient crease mortality. We describe a case in which the denied chest pain, headache, photophobia, neck diagnosis of infective endocarditis was established stiffness, cough, sore throat, or abdominal pain. On after the patient developed a cutaneous vasculitis. further questioning it was found that 2 days earlier she underwent an unsuccessful declotting proce- Methods dure of her dialysis graft site and placement of a left We describe a case of cutaneous vasculitis leading internal jugular intravenous catheter for temporary to the diagnosis of infectious endocarditis. A MED- dialysis access. LINEreview of the literature was performed using The patient was an obese woman in moderate distress. She was oriented only to name and place. Her temperature was 103.9°F, blood pressure was Submitted 14 March 2001. 142/70 mm Hg, heart rate was 96 beats per minute, From the Department of Family Medicine (TC, BB), and respiratory rate was 32/min. When examined, University of Maryland, Baltimore. Address reprint requests to Beth Barnet, MD, Department of Family Medicine, Uni- she had normal head, ear, eye, neck, and throat versity of Maryland, 29 S. Paca St, Baltimore, MD 21201. findings and basilar crackles at the left lung field. A Diagnosis of Infective Endocarditis 451 J Am Board Fam Pract: first published as on 1 November 2001. Downloaded from Figure 1. Prupuric rash on right ankle and foot. 3/6 systolic murmur heard best at the left sternal transthoracic echocardiogram showed left ventric- border was unchanged from her baseline. Her ab- ular global dysfunction, an ejection fraction of 25% domen was soft and nontender. Bowel sounds were to 30% (similar to her baseline), and no vegeta- present; abdominal palpation found no hepato- tions. On hospital day 3, the organism was identi- splenomegaly. Her extremities showed no edema, fied as methicillin-resistant Staphylococcus aureus. clubbing, or cyanosis, and pulses were 2ϩ and sym- Vancomycin and gentamicin were continued and, http://www.jabfm.org/ metrical. There was no thrill or bruit from her although her temperature returned to normal, she graft. She had 5/5 strength in all four extremities, remained bacteremic. She began to complain of deep tendon reflexes were 1ϩ, and sensation was abdominal pain. Findings on her abdominal exam- mildly decreased over both feet. There were no ination were normal, her stool was negative for skin lesions, and the left internal jugular catheter occult blood, and a computed tomographic abdom- site was clean with no erythema noted. inal scan was unremarkable. A procedure to declot on 23 September 2021 by guest. Protected copyright. In the emergency department laboratory studies her graft was unsuccessful, and on hospital day 6 disclosed the following values: white cell count the graft was removed along with her left internal 15 ϫ 103/␮L with 22% band cells, hemoglobin jugular line. Findings on a repeat transthoracic 12.2 g/dL, hematocrit of 31.6%, and platelet count echocardiogram were unchanged from the previous 230 ϫ 103/␮L. Blood urea nitrogen was 86 mg/dL, one. and creatinine was 9.8 mg/dL, similar to her base- The patient’s blood cultures became negative on line renal function studies. Findings on a chest hospital day 9, and a right internal jugular line was radiograph and a computed tomographic head scan inserted. She remained on vancomycin, but the were normal. Lumbar puncture showed no cells, gentamicin was discontinued. Her abdominal pain glucose and protein values were normal, and stains continued. On hospital day 10, the patient devel- were negative. Blood, urine, and cerebrospinal fluid oped a purpuric rash on her right ankle that ap- specimens were sent for culture. peared to be vasculitic. During the next 3 days the The patient was admitted to the hospital with a rash became distributed over her lower extremities presumptive diagnosis of sepsis resulting from her to her thighs (Figures 1 and 2). Differential diag- recent graft instrumentation, and she was given noses that were considered included infection, drug empiric antibiotic therapy (vancomycin and genta- reaction, Henoch-Scho¨nlein purpura, underlying micin). On hospital day 2, six of eight blood culture cancer, and connective tissue disease. Laboratory bottles grew gram-positive cocci in clusters. A studies were ordered. Her erythrocyte sedimenta- 452 JABFP November–December 2001 Vol. 14 No. 6 J Am Board Fam Pract: first published as on 1 November 2001. Downloaded from Figure 2. Rash distributed over her lower extremities within 3 days. tion rate was 54 mm/h. Tests for antinuclear anti- intravascular catheterization, intravenous drug use, body, human immunodeficiency virus, rheumatoid mitral valve prolapse with valve redundancy, and factor, hepatitis, and cryoglobulins were negative. prosthetic valves.3 Complications, including meta- A biopsy of the rash with immunofluorescent stain- static abscesses, are common. The risk of death 4 ing for immune complexes was negative. His- increases with the occurrence of complications, http://www.jabfm.org/ topathologic findings were consistent with a leuko- and mortality rates as high as 40% are observed cytoclastic vasculitis, and biopsy cultures grew with S aureus infective endocarditis. methicillin-resistant S aureus. On hospital day 17 a transesophageal echocardiogram showed a small, Clinical Characteristics mobile echodensity on the mitral valve. The pa- Signs and symptoms of infective endocarditis result tient’s condition was diagnosed as infective endo- from either local destructive effects of the cardiac on 23 September 2021 by guest. Protected copyright. carditis. endothelial surface, metastatic embolization of in- fected fragments to distant sites, hematogenous Discussion seeding of other sites, or antibody formation and Epidemiology deposition of immune complexes in tissues. Typical The overall incidence of infective endocarditis is clinical features of infective endocarditis are con- 1.7 to 4.0 per 100,000 population.1 In patients stitutional symptoms of fever, chills, and malaise older than 50 years, the incidence of infective en- with persistent bacteremia and a new or changing docarditis exceeds 15 per 100,000 population.2 In heart murmur. In up to 40% of patients, infective addition to age, other risk factors include male sex, endocarditis caused by S aureus is associated with congenital and rheumatic heart disease, mitral valve embolic complications.3,5 prolapse, prosthetic valves, previous occurrence of Embolic complications can occur as neurologic infective endocarditis, intravenous drug use, and abnormalities, arthralgias, or vasculitis and can fo- nosocomial instrumentation.2 cus attention away from the underlying cardiac Numerous microbial organisms with variable cause.3 Such complications initially might obscure virulence can cause infective endocarditis. S aureus the diagnosis of endocarditis, as in our patient’s is the most