Winning Abstracts from the 2008 Medical Student Abstract Competition: Acute Staphylococcus Aureus Endocarditis: Early/rapid diagnosis by recognition of the classical peripheral manifestations of infective endocarditis.
Sudy E. Jahangiri, BS. Northeastern Ohio University
The current incidence of infective endocarditis is 1 case per 1,000 hospital admissions and has not changed since the 1970ís. Classic peripheral manifestations of infective endocarditis (IE) have a decreased historical prevalence of 50% to current day prevalences of 10-23% for Oslerís nodes, 15% for splinter hemorrhages, and less than 10% for Janeway lesions. It is therefore uncommon for current medical students and residents to have seen these lesions in a patient with IE. We present a patient with acute Staphylococcus aureus IE due to injection drug use (IDU) with these classic peripheral manifestations in order to better acquaint current student and resident physicians with these classic manifestations.
A 24 year-old male with a history of IDU presented to the emergency department with left shoulder pain and fever of 102.3. On examination he was found to have left sternoclavicular (SC) joint tenderness and his white blood cell count was 13.1. He was admitted with suspected SC joint infection, started on vancomycin, piperacillin/tazobactam, and gentamicin, and scheduled for joint aspiration. Blood cultures were also drawn. The aspiration fluid was sterile with no neutrophils. The next day, the patientís left second toe and left index finger were ecchymosed and tender. A transesophageal echocardiogram was completed and read as normal. At this time, the patient left against medical advice. Three days later, the patient returned to the hospital with increasing lesions. By this time his original blood cultures were positive for Staphylococcus aureus. On examination, he had multiple Janeway lesions, Oslerís nodes on his left second toe and left fifth metatarsal joint, splinter hemorrhages on his left index finger, and right subconjuctival petechiae. No murmurs were audible. Intravenous vancomycin and rifampin were begun but the patient again signed out against medical advice and was lost to follow-up.
This patient with acute IE diagnosed by physical diagnostic signs and positive blood cultures provides a potent visual and clinical review of the classical but now uncommon presentation for this widely recognized disease process. The negative TEE results in this case serve as a reminder that an echocardiographic abnormality is not required for the diagnosis of IE. Physical diagnosis is still a potent means of recognition of a potentially life-threatening infectious disease.
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