What is your clinical
diagnosis?
a. Chest infection
b. Pyrexia of unknown origin
c. Infective endocarditis
What further history
would you like to obtain from the patient?
a. Travel history
b. Dental treatment history
c. Physical examination findings by family doctors, if any
d. All of the above
What further investigations
would you like to order?
a. Urine examination
b. Blood culture
c. Echocardiogram
d. All of the above
What treatment would
he need for your diagnosis?
a. Full intravenous course of antibiotic
b. Blood transfusion
c. Diuretic
d. Beta-blockade therapy
a
The clinical features of this young man are highly suggestive of infective endocarditis with decompensating mitral regurgitation. An echocardiogram was performed, which showed large vegetations on his mitral valve leaflets with severe mitral regurgitation (Figures 1 & 2). The left ventricular systolic function was still preserved but the marked tachycardia is indicative of decompensation with imminent heart failure.
The insidious course of this gentleman with on-and-off low grade fever requires a high index of suspicion of infective endocarditis. He has no history of dental procedures in the most recent year and he has no travel history. The unexplained anaemia and vasculitic lesions provided hints to the diagnosis and the pansystolic murmur further made the diagnosis of infective endocarditis obvious.
Further work-up includes blood culture (3 samples at different times and different sites) and urine examination for any feature of glomerulonephritis. With a history of antibiotic treatment, the sepsis may be partially treated and blood culture may be negative. The diagnostic of infective endocarditis is usually established with the Duke criteria. Definitive diagnostic criteria include pathological and clinical criteria. Pathological criteria refer to isolation of positive typical microorganisms by culture or histology. Clinical criteria refer to two major criteria, one major and three minor criteria or five minor criteria. Major criteria include positive blood culture and evidence of endocardial involvement by positive echocardiogram findings or new valvular regurgitation. Minor criteria include predisposing heart condition, fever, vascular phenomena, immunological phenomena and microbiological evidence not meeting major criterion.
This young man requires a full course of high-dose antibiotic therapy for 4 weeks. In view of the mobile nature and the large size of the vegetation with severe mitral regurgitation, surgical intervention with removal of vegetation and valve repair/replacement will be needed.
Figure 1. Vegetation on mitral valve (see arrow).
Figure 2. Severe mitral regurgitation.
