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1998 Presentations for the Poster and Vignette Sessions
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A CASE OF STAPHYLOCOCCUS AUREUS ENDOCARDITIS WITH TYPICAL SKIN LESIONS, AND A COMPLETE REMISSION OF ACUTE RENAL FAILURE. Xiaogang Zhang MD; Susan Kamper MD; John Olson MD; Marshfield Clinic, Marshfield, WI

54-year-old man with a history of rheumatic fever in childhood and heart murmur presented with fever, malaise , myalgias and arthralgias for 5 days. Cardiac auscultation revealed a grade 3/6 holosystolic murmur at the apex which radiates to the lower left sternal border. Two separate blood cultures were positive for staphylococcus aureus. Admission laboratory data included: BUN 94, Cr. 6.6; Urinalysis had 11-20 RBCs, 0-2 RBC casts and 40mg/dl protein; Liver function tests (LFTs) showed total bilirubin 6.6, direct 5.5, AST 112, ALT 75, GGT 271. (Bun, Cr. and LFTs became normal 7 days later). Transthoracic (TTE) echocardiography showed moderate mitral valve insufficiency, thickening and prolapse without overt vegetations. Cefazolin and Gentamicin were started. During the course, he developed painful skin lesions on the fingertips and a painless lesion on the sole from day 2 to day 4. The second TTE on day 14 was stable. On day 23, he noted another painful red lesion over the dorsum of the left foot measuring 3 cm in diameter. The third TTE showed worsening mitral insufficiency and new pulmonary hypertension. Mitral valve replacement was done on day 24. Pathology report showed destructive mitral valvulitis with a large septic vegetation containing gram-positive cocci.

Discussion: 1) The patient met one major Duke's criterion and at least 3 minor criteria, regardless of TTE findings. Serial TTE could monitor mitral valve damage , but failed to detect the vegetations. 2) The patient developed at least two classic types of associated skin lesions. One was noted as irregular, nontender, hemorrhagic, with diameter from 1mm to 4 mm, consistent with Janeway lesion. The other type lesion was tender, indurated, blanchable, and had a round to oval outline, which is consistent with Osler's node. These lesions had been stable at least for two weeks. 3) Glomerulonephritis is the possible mechanism for the acute renal failure, which is supported by the active urinary sediment. The patient had normal Cr. during the embolic phenomenon, aminoglycoside treatment and cardiac surgery. Another possible mechanism is sepsis syndrome associated with multiple organ failure. The patient had simultaneous LFTs abnormalities. The patient recovered completely from the advanced renal failure.

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