76

CASE 76


A 62-year-old man was seen in his family physician’s office for complaints of low-grade fevers, night sweats, and fatigue for 3 weeks.


The patient had a history of a heart murmur but had never undergone extensive evaluation. He had been in generally excellent health with normal exercise tolerance. Approximately 6 weeks ago he underwent an uncomplicated extraction of an impacted wisdom tooth but received no antibiotics prior to the procedure.



PHYSICAL EXAMINATION



VS: T 38°C, P 104/min, R 14/min, BP 130/82 mmHg

PE: The patient was alert; a rough, diamond-shaped systolic murmur—heard loudest in the upper left sternal border—was noted. A “splinter hemorrhage” in the nail of his right index finger and conjunctival petechiae were also noted. His spleen was palpable as well.


LABORATORY STUDIES



Blood



ESR: 80 mm/h

Hematocrit: 36%

WBC: 10,500/μL

Differential: 74% PMNs, 18% lymphs

Serum chemistries: Normal

Urinalysis: WBC 5 to 10/μL, RBC 10 to 20/μL, no bacteria

Coagulation panel: Normal


Imaging


A chest x-ray was within normal limits.



Diagnostic Work-Up


A clinical diagnosis of infective endocarditis (IE) was considered, based on the symptoms and peripheral manifestations. Table 76-1 lists the likely causes of IE (differential diagnosis). Investigational approach may include


TABLE 76-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Enterococci

Fungi

Gram-negative aerobic bacilli

HACEK organisms
Haemophilus

Actinobacillus

Cardiobacterium

Eikenella

Kingella

Miscellaneous bacteria (e.g., Chlamydia, Coxiella, and Bartonella)

Oral bacteria (e.g., viridans streptococci)

Staphylococcus aureus

Staphylococcus epidermidis

Streptococcus pneumoniae

Rationale: The clinical syndrome presented above is nonspecific and may be seen with a variety of infectious as well as noninfectious causes. Endocarditis is an important consideration, especially in older individuals and in those with specific risk factors. S. aureus, viridans streptococci, S. epidermidis, entero-cocci, and S. pneumoniae are commonly encountered.



• Echocardiography (echo). Useful when endocarditis is suspected; transesophageal echo is more sensitive than is transthoracic echo

• Blood cultures

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 76

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