An intricate case of infective endocarditits

Objective: Infectious endocarditis is a pathology with a polymorphic clinical picture and prognosis dependent on the occurrence of complications. A predisposing factor is the presence of valvular anomalies, backed up by a relatively increased number of patients with undi-agnosed congenital heart diseases. Among the frequent complications suffered following infectious endocardi-tis, we find heart failure, ischemic strokes, cerebral ab-scesses, whereas meningitis or endophthalmitis are less common complications. Typically, its diagnosis begins with manifestations of heart failure, however, the ab-sence of such signs and symptoms, in association with negative blood cultures, delays the diagnostic process. Methods: We present the clinical case of a 50-year-old patient with unknown pathological history, whose symptomatology suddenly begins with neurological manifestations and fever. After a lumbar puncture (clo-udy CSF and negative cultures in biological samples) he was diagnosed with meningoencephalitis by the In-fectious Disease Hospital. Under broad-spectrum anti-biotic treatment and constant monitoring of biological parameters and renal function, the patient accuses a decrease in visual acuity; following the ophthalmologic consultation, the conclusion was that he suffered from bilateral endophthalmitis and retinal detachment in the right eye. Later on, the patient accuses dyspnea, which urges a cardiological exam and echocardiography.

Results: Due to the prolonged aggressive antibiotic treatment, when the patient was admitted to Cardio-logy ward, he was afebrile, with modest inflammatory syndrome (CRP=14 mg/L), but with modified kidney function tests (creatinine=2.53 mg / dl, urea=73 mg/ dl)- acute iatrogenic renal insufficiency with preser-ved diuresis. Clinically, sinus tachycardia- 95 bpm, BP 100/40mmHg, diastolic murmur III / VI in the aortic area. EKG – left ventricular hypertrophy. Transthoracic echocardiography revealed global cardiomegaly with reduced ejection fraction (LVEF 47%); aortic bicuspid valve; major aortic regurgitation through a paraval-vular fistula and a perforation of the posterior aortic cusp; severe pulmonary hypertension (estimated pul-monary artery systolic pressure 70 mmHg); patent fo-ramen ovale with left-right shunt which decompresses the left cavities and limits the increase in pulmonary circulation pressures. Under heart failure treatment, an improvement in cardiac function has been achieved. Subsequently, the patient was transferred to a cardio-vascular surgery ward where an aortic valve prosthesis was performed. After surgery, an immediate recovery with a reduction in heart size and an increase of the ejection fraction was noticed.

Conclusions: Infective endocarditis lacking the initial cardiac symptoms while presenting negative blood cul-tures is a major diagnostic challenge and usually, has a poor prognosis. The presented case is particular due to the rare location of septic complications (meninge and eyes), which had long preceded the installation of cardiovascular symptomatology in a patient with an undiagnosed aortic bicuspid valve. Moreover, an unu-sual consequence of the complications in this patient is bilateral permanent blindness, as a result of the sep-tic embolism. In the face of such a complex and subtle pathology, we emphasize the need to set up a multi-disciplinary working group for prompt diagnosis and appropriate treatment.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)