Posted: June 10th, 2024

Infective Endocarditis Case Study

Here is a draft of an academic paper on infective endocarditis based on the provided case study, following the requested guidelines:

Infective Endocarditis Case Study

Infective endocarditis (IE) is a serious infection of the endocardial surface of the heart, most commonly affecting the heart valves (Holland et al., 2016). If left untreated, IE can lead to severe complications and death. This paper presents a case study of a 63-year-old male patient diagnosed with IE, analyzing the clinical manifestations, risk factors, diagnostic criteria, and appropriate treatment for this condition.

Case Presentation
The patient, Mr. H.Y., presented to the emergency room with a two-day history of high-grade fever, chills, and painful nodules on his fingers and toes. His medical history included asthma, rheumatic fever with mitral valve replacement, hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), tobacco abuse, and alcoholic liver disease. The patient reported having an infected tooth removed two weeks prior without receiving antibiotic prophylaxis.

Physical examination revealed a tachycardic, febrile, and diaphoretic patient with poor dentition and a new diastolic murmur along the left sternal border. Tender, red to purple nodules (Osler nodes) were observed on the patient’s fingers and toes. Laboratory results showed elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein, as well as anemia and thrombocytopenia. Blood cultures were positive for Streptococcus viridans. Transthoracic echocardiography revealed a 3-cm vegetation on the aortic valve.

Discussion
The patient’s clinical presentation, including acute onset of symptoms, presence of Osler nodes, and positive blood cultures, is consistent with acute IE (Cahill & Prendergast, 2016). Several risk factors contributed to the development of IE in this patient. Rheumatic fever with mitral valve replacement, poor dentition, and the recent dental procedure without antibiotic prophylaxis are significant predisposing factors (Toyoda et al., 2017). Additionally, diabetes mellitus and alcoholic liver disease may have impaired the patient’s immune response, increasing susceptibility to infection (Habib et al., 2019).

The Modified Duke Criteria were used to diagnose IE in this case. The patient met two major criteria: positive blood cultures for a typical IE organism (S. viridans) and evidence of endocardial involvement on echocardiography (3-cm aortic valve vegetation). The presence of Osler nodes, a minor criterion, further supported the diagnosis (Li et al., 2020).

Elevated inflammatory markers (WBC, ESR, CRP) and anemia are common laboratory findings in IE, resulting from the systemic inflammatory response and chronic infection (Hubers et al., 2018). Thrombocytopenia may occur due to platelet consumption during thrombus formation on the infected valve (Liesenborghs et al., 2020). The absence of proteinuria and hematuria in this case suggests that the patient had not yet developed glomerulonephritis, a potential complication of IE.

The appropriate pharmacologic treatment for this patient is intravenous antibiotic therapy targeting S. viridans. The specific antibiotic regimen should be based on the organism’s susceptibility profile and the patient’s clinical status (Baddour et al., 2015). Close monitoring for complications and early surgical intervention may be necessary if the patient develops heart failure, persistent infection, or embolic events.

Conclusion
This case study highlights the importance of recognizing risk factors, clinical manifestations, and diagnostic criteria for IE. Prompt diagnosis and appropriate antibiotic treatment are essential to prevent complications and improve patient outcomes. Healthcare providers should maintain a high index of suspicion for IE in patients with predisposing conditions and ensure adequate antibiotic prophylaxis for dental procedures in high-risk individuals.

References
Baddour, L. M., Wilson, W. R., Bayer, A. S., Fowler, V. G., Tleyjeh, I. M., Rybak, M. J., … & Bolger, A. F. (2015). Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation, 132(15), 1435-1486.

Cahill, T. J., & Prendergast, B. D. (2016). Infective endocarditis. The Lancet, 387(10021), 882-893.

Habib, G., Erba, P. A., Iung, B., Donal, E., Cosyns, B., Laroche, C., … & Lancellotti, P. (2019). Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. European heart journal, 40(39), 3222-3232.

Holland, T. L., Baddour, L. M., Bayer, A. S., Hoen, B., Miro, J. M., & Fowler, V. G. (2016). Infective endocarditis. Nature reviews Disease primers, 2(1), 1-49.

Hubers, S. A., DeSimone, D. C., Gersh, B. J., & Anavekar, N. S. (2018). Infective endocarditis: a contemporary review. Mayo Clinic Proceedings, 93(11), 1603-1616.

Li, J. S., Sexton, D. J., Mick, N., Nettles, R., Fowler, V. G., Ryan, T., … & Corey, G. R. (2020). Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clinical infectious diseases, 30(4), 633-638.

Liesenborghs, L., Meyers, S., Lox, M., Criel, M., Claes, J., Peetermans, M., … & Verhamme, P. (2020). Staphylococcus aureus endocarditis: distinct mechanisms of bacterial adhesion to damaged and inflamed heart valves. European Heart Journal, 41(30), 2901-2910.

Toyoda, N., Chikwe, J., Itagaki, S., Gelijns, A. C., Adams, D. H., & Egorova, N. N. (2017). Trends in infective endocarditis in California and New York state, 1998–2013. Jama, 317(16), 1652-1660.

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Infective Endocarditis Case Study
PATIENT CASE
HPI
Mr. H.Y. is a 63-year-old male, who presents to the ER with a two-day history of high-grade fever with chills. “I don’t feel well and I think that I may have the flu,” he tells the ER nurse and physician. He also complains of “some painful bumps on my fingers and toes that came on last night.” He denies IVDA. When asked about recent medical or dental procedures, he responded: “I had an infected tooth removed about two weeks ago.” He does not recall receiving any antibiotics either prior to or after the procedure.
Patient Case Question 1. Which type of infective endocarditis is suggested by the
patient’s clinical manifestations—acute or subacute?
PMH
• Asthma since childhood
• Rheumatic fever as a child
2 with mitral valve replacement 2 years ago
• HTN
20 years
• DM type 2,
9 years
• COPD
4 years
• H/O tobacco abuse
• Alcoholic liver disease
Patient Case Question 2. Which three of the illnesses in this patient’s medical history may be contributing to the onset of infective endocarditis and why are these diseases considered risk factors?
CASE STUDY
INFECTIVE ENDOCARDITIS 7
For the Disease Summary for this case study,
see the CD-ROM.
FH
• Mother died from CVA at age 59; also had ovarian cancer
• Father had H/O alcohol abuse; suffered AMI at age 54; DM type 2; died in his 60s from
pancreatic cancer that “spread to his bones”
SH
• Married for 43 years, recently widowed and lives alone
• Father of 4 and grandfather of 10
• One son lives in same city, but his other children live in other states
• Insurance salesman who retired last year
• Monthly income is derived from social security, retirement account, and a small life insurance benefit following his wife’s death (breast cancer)
• Manages his own medications, has no health insurance, and pays for his medications
himself
• 45 pack-year smoking history, but quit when he was diagnosed with emphysema
• Has a history of alcohol abuse, but quit drinking 4 years ago; continues to attend AA meetings regularly and is active in his church as an usher and Prayer Warrior
ROS
• Patient denies any pain other than the lesions on his fingers and toes
• Denies cough, chest pain, breathing problems, palmar or plantar rashes, and vision
problems
• () for mild malaise and some loss of appetite
Patient Case Question 3. What is the significance of the absence of breathing problems,
chest pain, rashes, and visual problems?
Meds
• Theophylline 100 mg po BID
• Albuterol MDI 2 puffs QID PRN
• Atrovent MDI 2 puffs BID
• Nadolol 40 mg po QD
• Furosemide 20 mg po QD
• Metformin 850 mg po BID
Patient Case Question 4. For which two disease states might the patient be taking theophylline?
Patient Case Question 5. Which medication or medications is the patient taking for diabetes?
Patient Case Question 6. Which medication or medications is the patient taking for high blood pressure?
CARDIOVASCULAR DISORDERS
All
Penicillin (rash, shortness of breath, significant swelling “all over”)
Patient Case Question 7. Why are the clinical manifestations of the penicillin allergy so
significant?
PE and Lab Tests
Gen
The patient is a significantly overweight, elderly male in moderate acute distress. His skin is
pale and he is slightly diaphoretic. He is shivering noticeably.
Vital Signs
See Patient Case Table 7.1
Patient Case Table 7.1 Vital Signs
BP 150/92 RR 23 and unlabored Ht 510
P 118 T 102.5°F Wt 252 lb
Patient Case Question 8. Is this patient technically considered overweight or obese?
Skin/Nails
• Very warm and clammy
• No rashes
• No petechiae or splinter hemorrhages in nail beds
• Multiple tattoos
• No “track” marks
Patient Case Question 9. What is the significance of the absence of “track” marks?
HEENT
• Anicteric sclera
• PERRLA
• EOMI
• Conjunctiva WNL
• No retinal exudates
• TMs intact
• Nares clear
• Oropharynx benign and without obvious lesions

• Mucous membranes moist
• Poor dentition
Neck
• Supple
• () for lymphadenopathy, JVD, and thyromegaly
Heart
• Tachycardia with regular rhythm
• Normal S1 and S2
• Diastolic murmur along the left sternal border (not previously documented in his medical
records), suggestive of aortic regurgitation
Patient Case Question 10. What is the most significant and relevant clinical finding in
the physical examination so far and what is the pathophysiology that explains this clinical sign?
Chest
• CTA throughout
• Equal air entry bilaterally
• No wheezing or crackles
• Chest is resonant on percussion
Abd
• Soft and non-tender
• () bowel sounds
• No organomegaly
Genit/Rect
Deferred
Ext
• No CCE
• Reflexes bilaterally 5/5 in all extremities
• Small, tender nodules that range in color from red to purple in the pulp spaces of the
terminal phalanges of the fingers and toes (“Osler nodes”)
Neuro
• No focal deficits noted
• A & O
3
Laboratory Blood Test Results
See Patient Case Table 7.2
B
30 PART 1 ■ CARDIOVASCULAR DISORDERS
Patient Case Question 11. Identify five elevated laboratory test results that are consistent with a diagnosis of bacterial endocarditis.
Patient Case Question 12. Explain the pathophysiology for any three of the five elevated
laboratory results identified in Question 11 above.
Patient Case Question 13. Identify two subnormal laboratory results that are consistent
with a diagnosis of bacterial endocarditis.
Urinalysis
The urine was pale yellow, clear, and negative for proteinuria and hematuria. A urine toxicology screen was also negative.
Patient Case Question 14. Explain the pathophysiology of proteinuria and hematuria in
a patient with infective endocarditis.
ECG
Normal
Transthoracic ECHO
A 3-cm vegetation on the aortic valve was observed. No signs of ventricular hypertrophy or
dilation were seen.
Blood Cultures
3 of 3 sets () for Streptococcus viridans (collection times 1030 Tuesday, 1230 Tuesday, 1345
Tuesday)
Patient Case Question 15. What are the six diagnostic Modified Duke University criteria
that favor a diagnosis of infective endocarditis in this patient?
Patient Case Question 16. What is the appropriate pharmacologic treatment for this
patient?

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