BRIEF HISTORY
A 60-year-old woman was admitted through the outpatient clinic with a four-month history of weight loss, loss of appetite and fever with rigors and night sweats. She also complained of increased breathlessness and tiny reddish lesions on the palms and pulp of the fingers which were painful. She also had some dragging sensation in the left hypochondrium. In the past, she was operated for mitral valve stenosis by valvotomy. She was a known hypertensive and diabetic. IMPORTANT CLUES ON
CLINICAL EXAMINATION
On examination, she looked pale and had a temperature of 100° F. She was clubbed and there were a few streaks in her nails. Pulse was 108 per minute regular, and all the pulses were palpable. Heart sounds were normal, but there was a pan-systolic murmur at mitral area which radiated towards left axilla. Chest was clear but abdominal examination revealed splenomegaly. Neurological examination was normal.
INVESTIGATIONS
Investigations included:
| Hb: |
8.4 g/dl (normocyticand a few normochromic) |
| WBC: |
16.6 × 109 /l
P:71% L:21%
M:5% E:3%
|
| Urine: |
traces of albumin and a few RBCs per high |
| Chest X-ray: |
mitralization of the left border of heart with prominent pulmonary blood vessels. |
| ESR: |
95 mm in 1st hour |
| Sodium: |
140 mmol/l |
| Potassium: |
4.3 mmol/l |
| Bicarbonate: |
25 mmol/l |
| Chloride: |
110 mmol/l |
QUESTIONS
Q.1. What is the diagnosis?
Q.2. What further investigations would you ask for?
Q.3. What possible organisms are involved?
Q.4. What do you know in reference to Libman Sacks?
Q.5. What are the vasculitic lesions of this disorder?
Q.6. What is the treatment?
Medicine
A.1. The history, examination and investigations lead to a diagnosis of infective endocarditis.
A.2.
i. Blood cultures: At least four to six sets of blood culture are required, but one should be aware of special media for other organisms. At least 5 to 10 ml of blood should be withdrawn for each example.
ii. Echocardiogram: To see any vegetations on the mitral valve.
A.3. 1. Streptcoccus viridans 7. Brucella
2. Streptococcus faecalis 8. Listeria
3. Staphylococcus aureus 9. Candida
4. Pneumococcus 10. Aspergillus
5. Gonococcus 11. Coliform bacteria
6. Histoplasma 12. Coxiella burnetti
A.4. These are non-infective vegetations which occur in systemic lupus erythematosis called Libman-Sacks endocarditis.
A.5. The vasculitic lesions include, Oslers nodes, which are tender subcutaneous nodules and are purplish or reddish. They classically occur on finger pulps. Janeways lesions are large, erythematous, painful and tender maculo-papular lesions which may develop on the palms or soles. Roths spots are small, flame-shaped haemorrhages which are found in the retina and may also have a pale centre.
A.6. Mostly it is streptococcus viridans and, therefore benzyl penicillin is the treatment of choice which is supplemented with gentamycin for synergistic effect. The former should be given parenterally for four weeks, while the latter can be given for the first two weeks. Pencillinase resistant penicillin analogues should be used in cases due to penicillin-resistant organisms, e.g. methicillin, oxacillin, nafcillin, cephalosporins, etc. In patients who are allergic to penicillin, erythromycin, cephalosporins and vancomycin are alternative drugs. Fungal infections are treated with amphotericin B therapy. If bacterial endocarditis develops more than six weeks after the cessation of treatment, it usually is a new infection.
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