Infectious endocarditis - An ever-present suspicion

Abstract

Introduction: An elevated level of suspicion is required to make a timely diagnosis of infective endocarditis. The family physician with knowledge of the risk factors of each patient is in a privileged position to diagnose this disease. Case Description: A 59 year-old male patient with a history of 3 previous episodes of infective endocarditis has been treated in our practice since 2007. Two episodes were associated with a prosthetic valve (a consequence of the first episode). He was seen recently for an episode of fever of unknown origin associated with high serum levels of markers of inflammation. Two echocardiograms performed in hospital were non-diagnostic. The family physician retained a suspicion of infective endocarditis in this high-risk patient. Ambulatory blood cultures were positive for Enterococcus faecalis. The patient was again sent to the hospital and the echocardiogram now revealed a cardiac vegetation, confirming the diagnosis of infective endocarditis, 20 days after the initial onset of symptoms. At the beginning of the second month of his stay at the hospital, the patient suffered a hemorrhagic stroke, leaving him with dysarthria and a right hemiparesis. Discussion: Although infective endocarditis is a rare disease, it has high morbidity and mortality when associated with prosthetic heart valves. The presentation of the disease is variable, so the physician needs a high level of suspicion to make a prompt diagnosis and prevent long-term consequences. The Duke criteria may help with diagnosis. However, the sensitivity of the criteria is reduced in patients with prosthetic valves. This is a sub-acute case of endocarditis, in which the diagnosis was made with positive blood cultures after 20 days of symptoms. Persistent suspicion of endocarditis by the family doctor enabled a timely diagnosis.