Clinical Geriatrics

CASE PRESENTATION
A 62-year-old functional but cachectic male, who was able to ambulate with a walker, presented to the emergency department (ED) with a temperature of 102.3 degrees F, and neck and low back pain. The patient reported having had subjective fever and chills at home starting 1 week prior to the hospital visit. He also reported generalized fatigue, occasional shortness of breath, and a 20-pound weight loss over 2 weeks. There were no reported changes in mental status. The patient did have a recent history of having had a left carotid sinus takedown with removal of the optic nerve in order to treat invasive aspergillosis infection of the left orbital apex 1 month previously. This infection had extended into the left sinuses and left optic nerve. During the surgery, which did have a good outcome with no immediate complications, a central line had been placed for venous access.

Investigation
The patient’s past medical history included coronary artery disease, a cerebrovascular accident in 1985 with no residual deficits, depression, non-insulin–dependent diabetes mellitus, chronic atrial fibrillation, and hypertension. Medications taken were glipizide, fosinopril, warfarin, and sertraline. On physical examination there were no meningeal signs. He denied chest pain or shortness of breath. The exam was remarkable for closed left eyelid, which the patient could not open, with no erythema, swelling, or drainage of the surrounding tissue. A healing left neck scar was evident with well-granulated suture sites. The patient also had a laceration extending from the left frontal to the left side of the scalp, with staples still in place; the wound was clean and dry. A Hickman catheter was attached at the right upper chest. The heart had a regularly irregular rhythm, with distant heart sounds and a 2/6 systolic ejection murmur, which was new by history. There was no clubbing, cyanosis, or edema in the lower extremities, and no Kernig or Brudzinski signs.

White blood cell count was slightly elevated to 11.2/mm3 with a normal differential. Hemoglobin and hematocrit were both decreased to 10 g/dL and 31.5%, respectively. Complete metabolic panel, including liver function tests and albumin, were within acceptable ranges.

Management and diagnosis
The patient was empirically started on ceftriaxone sodium and vancomycin, and a lumbar puncture was performed to rule out meningitis. Blood cultures were taken and a urinalysis was performed. After admission to the hospital, a two-dimensional echocardiography was done and revealed an ejection fraction of 45%. An abscess of perforation on the posterior leaflet of the mitral valve was also seen on echocardiography, and it was recognized that this could have represented a vegetation as well. In addition to severe mitral regurgitation, the test showed elevated right-sided pressures and mild mitral valve prolapse. A transesophageal echocardiogram (TEE) was scheduled, and when done confirmed severe mitral regurgitation, pulmonary vein flow reversal, a small vegetation and perforation of the posterior leaflet of the mitral valve, and a small patent foramen ovale.

Blood cultures initially showed gram-positive cocci that subsequently grew Staphylococcus aureus, confirming the diagnosis of an endocarditis on the mitral valve, thought to be due to contamination by the Hickman catheter.

GENERAL ASPECTS OF INFECTIVE ENDOCARDITIS
Infective endocarditis (IE) is an infection of the endocardium of the heart involving significant disease processes of the valvular portions. Infection accumulates at a localized site of the endocardium that is damaged by a process such as a foreign body or jets of turbulent blood flow. Bacteria from various sources, such as the skin, gastrointestinal (GI), respiratory, or urinary tracts, enter and are carried through the bloodstream, eventually reaching this diminutive site of trauma, and lodging there.