Infective endocarditis – Alfa or Omega?

Introduction: Endocarditis is an infection of the endo-cardium, which occurs when bacteria spread through the bloodstream and attach to structures of the heart, especially valves. It is difficult to evaluate the inciden-ce and impact of bacterial endocarditis because many cases evolve with negative hemocultures. Meningitis is a complication of endocarditis, but it can also occur before the endocarditis. Endogenous endophthalmitis is a type of intraocular inflammation secondary to he-matogenous spread from a distant infective source and it is associated with systemic infections, meningitis and endocarditis.

Methods: Patient A.N., 49 years old, male, with chro-nic alcoholism was hospitalized for fever, headache, myalgia, hallucinations and signs of meningeal irritati-on. After the lumbar puncture, the patient was diagno-sed with acute meningoencephalitis, but the etiological agent was not isolated. The treatment was initiated with Meropenem and Vancomycin, to which Trimethoprim-Sulfamethoxazol was subsequently associated.

Results: After 17 days, the evolution being favorable, the treatment was changed to Ampicillin and Cefotaxi-me. In the following days, the patient experienced a de-crease in visual acuity in a feverish context. Following the investigations, he was diagnosed with endogeno-us endophthalmitis and retinal detachment of the ri-ght eye. The therapy was changed to Clindamycin and Vancomycin with apparently favorable evolution, until the patient installed sudden dyspnea. Transesophageal ultrasound established the diagnosis of endocarditis. Clindamycin was replaced by Rifampicin and Genta-micin, but because the patient’s urea and creatinine in-creased, the treatment was reshaped to Linezolid and Cotrimoxazole, with favorable evolution. Endocarditis accompanying meningitis is unusual and associated with an unfavorable prognosis. The presence of the three pathologies (acute meningoencephalitis, com-plicated with endophthalmitis and later with endocar-ditis) is even less common. In the case of meningitis with S. aureus, there is always a primary source, most commonly represented by pneumonia or endocarditis. Regarding meningitis with S. pneumoniae, endocarditis is always a complication. Although the suspicion of a primary endocardial source can not be excluded, it is known that alcoholism is a risk factor for pneumococ-cal meningitis. This aspect along with the installation of dyspnea after the healing of meningoencephalitis, advocates endocarditis as a complication. However, the development of endophthalmitis may be an argument for the existence of an endocardial process undergoing evolution.

Conclusions: The case described is of interest from the perspective of establishing the primary pathophysiolo-gical process based on clinical data, in the absence of an isolated etiological agent. The difficulty of the case is also reflected in the therapeutic management issues considering the development of the renal disease.

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)