RESUMEN

We discuss the case of a 60-year-old male who presented with ankle pain, a necrotic rash, and progressive weakness in both lower limbs and the right upper limb. An infectious workup of the skin lesions came back negative. Additionally, his kidney function tests indicated an acute kidney injury. This prompted investigations for vasculitis etiologies, which revealed a positive cytoplasmic antineutrophil cytoplasmic autoantibody (c-ANCA). His neurological deficits were also investigated, and imaging suggested embolic infarcts. Cardiac imaging showed valve vegetations and blood culture showed a lack of growth suggestive of a noninfective nature of these lesions. Based on all these findings, a kidney biopsy was obtained and demonstrated pauci-immune segmental vasculitis consistent with ANCA-associated glomerulonephritis. As such, the patient showed improvement with heavy pulse steroid and immunomodulator therapy. Although skin, heart, and CNS involvement have been previously reported with ANCA-associated vasculitis, it is rare, especially together, and can prove a diagnostic challenge. Therefore, it is important to consider vasculitis etiology in patients presenting similarly. In addition, this case highlights the overlapping clinical picture between infective endocarditis and vasculitis with valvular involvement, making differentiation between the two challenging.

RESUMEN

Infection from Coxiella burnetti causes Q fever that manifests with vague symptoms. We report a case of an individual admitted to the hospital with recurrent fevers with a history of multiple tick bites. Further workup revealed examination and laboratory findings consistent with Q fever endocarditis. Fevers resolved with doxycycline and hydroxychloroquine. Our case highlights that suspicion for Q fever should be maintained in patients presenting to the hospital with fevers of unknown origin for prompt recognition and appropriate treatment.

RESUMEN

Infective endocarditis is a severe medical condition that occurs when the endocardium of the heart gets infected by different microorganisms, including coagulase-negative staphylococci such as Staphylococcus lugdunensis. The source of infection is often related to procedures done in the groin area, such as femoral catheterization for cardiac catheterization, vasectomy, or central line placement in an already infected mitral or aortic valve. Herein, we are discussing a case of a 55-year-old female with a past medical history of end-stage renal disease on hemodialysis with a history of recurrent cannulation of her arteriovenous (AV) fistula. She presented with fever, myalgia, and generalized weakness, and was later found to have Staphylococcus lugdunensis bacteremia and infective endocarditis with mitral valve vegetations, for which the patient was transferred to the mitral valve specialized center for mitral valve replacement. This case acts as a reminder to consider recurrent cannulation of the AV fistula as one of the potential ports of entry of Staphylococcus lugdunensis to the body.

RESUMEN

Infective endocarditis (IE) can present with a wide variety of clinical signs and symptoms, making it difficult to diagnose. Recognizing risk factors such as congenital heart disease, intravenous drug use, and prosthetic heart valves can encourage early testing with blood cultures and echocardiography, leading to prompt diagnosis and treatment with antibiotics. Despite early detection and treatment, IE can still result in permanent damage of the affected heart valves, most commonly resulting in valvular regurgitation and signs and symptoms of heart failure. Clinicians must maintain a high index of suspicion as prompt diagnosis and treatment are essential to prevent morbidity and mortality. Valvular stenosis as a result of IE, unlike valvular regurgitation, is extremely rare and has only been described a handful of times in literature. We present a unique case of Streptococcus viridans IE resulting in functional mitral stenosis and recurrent flash pulmonary edema in an elderly female who had recently undergone a dental cleaning procedure.

RESUMEN

Libman-Sacks endocarditis (LSE) is a rare disease found incidentally in postmortem autopsies, characterized by microscopic to large verrucous vegetation on the cardiac valves, the most affected site is the mitral valve followed by the aortic valve. Females of reproductive age were observed as the most affected individuals as found in studies. Most individuals with LSE are asymptomatic and generally discovered lately when they presented with thromboembolic disorders such as stroke, cognitive disabilities, and death. Malignancy and autoimmune diseases involving systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are considered the primary etiology of LSE. As recognized, the majority of LSE cases are asymptomatic, it tends to be challenging to spot the condition at the early pathway of the disease. In this paper, we describe a young female who is known to have SLE on medications, she presented to the emergency department (ED) due to chest pain and exertional dyspnea for a few days, laboratory investigations showed anemia, raised inflammatory marker, and anti-DsDNA. Imaging studies showed bilateral pleural effusion on the chest X-ray and a large vegetation on the posterior mitral valve with moderate regurgitation and normal wall motion in transesophageal echocardiography. The patient was managed by pulse steroid therapy, anticoagulation therapy, and a low dose of diuretic, the patient improved dramatically and discharged home with close follow-up in the clinic. The primary treatment of LSE is anticoagulant therapy, however, surgical intervention should be considered in case of large vegetation recurrent thromboembolism despite anticoagulant therapy. As the prognosis in LSE is considered very poor and there is no definitive laboratory investigation exists to confirm the diagnosis, we highlight the importance of considering LSE as a serious and crucial differential diagnosis when dealing with SLE patients who presented with dyspnea and pleural effusion secondary to valvular dysfunction, mainly the mitral valve.

RESUMEN

A 7-year-old Liberian boy presented with fever, severe headache, neck pain and 'not being able to walk'. In the emergency room, his sickle cell screen was positive, and his haemoglobin level was 7 g/dl. Initially, he was admitted to the ward with a diagnosis of sickle cell painful crisis and was treated with ceftrixone iv, and oral morphine and paracetamol. In a more complete physical examination, he had left peripheral seventh nerve palsy, left sixth nerve palsy and ipsilateral hemiplegia, also neck rigidity. In a bedside ultrasound scan, he had a large, mobile vegetation on the aortic leaflet of the mitral valve. The final diagnosis was acute infective endocarditis with multiple embolic strokes in a child with sickle cell disease. Headache and neck rigidity was most likely due to SAH or meningitis.

Asunto(s)

RESUMEN

In the era of a pandemic, the utilization of telemedicine is growing at a rapid speed. This new and necessary adaption in medicine is a threat to the basics of medicine which include the physical exam. A 72-year-old woman presents for a 1-week history of cervical neck discomfort. The patient was found to be febrile with initial physical exam nonrevealing due to patient preference of not taking off hospital gown. After blood cultures grew group A beta-hemolytic streptococcus and a computed tomography scan of the abdomen and pelvis with contrast demonstrated subtle bilateral renal hypodensities suggesting possible septic emboli, a more thorough physical exam was sought out which revealed a large rodent ulcer which the patient had been hiding from her family for 2 years. Transthoracic echocardiography was done which demonstrated a vegetation on the mitral valve confirming the diagnosis of endocarditis. The source of infection was the ulcer which was biopsied and found to be basal cell carcinoma. We present a unique case of endocarditis that was reliant on the physical exam to reveal the source of infection which was a rodent basal cell carcinoma ulcer. This case reminds physicians that at the forefront of telemedicine, the physical exam should not be forgotten.

RESUMEN

We report a case of a 56-year-old man who presented initially with a sudden onset of right-sided facial droop and weakness, aphasia, and confusion with no associated fever, chills, syncope, fatigue, weight loss, night sweats, nausea, vomiting, diarrhea, odontalgia, palpitations, cough, or dyspnea. Code stroke was called and the patient received tissue plasminogen activator (tPA) with subsequent resolution of his symptoms. Cranial magnetic resonance imaging showed left frontal punctate cortical restricted diffusion consistent with subacute to acute infarction. Transesophageal echocardiogram showed a severely thickened anterior mitral valve leaflet with a shaggy echodensity consistent with a vegetation. Blood cultures grew Bacillus cereus sensitive to clindamycin, trimethoprim sulfamethoxazole, and vancomycin. He was initially treated with ampicillin, clindamycin, and vancomycin and was eventually maintained solely on vancomycin. He had complete return of his neurological function and was discharged on intravenous antibiotic to complete a 6-week course.

Asunto(s)

RESUMEN

Aortic saddle embolus accounts for approximately 10% of all peripheral arterial emboli. The most common sources of emboli are left atrial thrombi associated with atrial fibrillation and vegetation. A 22-year-old male patient was admitted due to acute onset of orthopnea, tachypea and cough. Transthoracic and transeophageal echocardiography showed huge vegetation (3X2cm) of the posterior mitral valve leaflet which was associated with severe mitral regurgitation. On 14th hospital day, he suffered from sudden onset of weakness, pain, and coldness on both lower extremities. Follow-up echocardiography showed marked size reduction of the original mitral valve vegetation. Angiography showed aortic saddle embolus. The embolectomy of aortic saddle embolus was performed through the transfemoral approach with a Forgarty catheter. At the same time, removal of the infected mitral valve and mitral valve replacement were performed.

Asunto(s)