Dario Aguilar presented a complicated patient presenting with fever, visual hallucinations, and a handful of other symptoms. In the end, the unifying diagnosis was infective endocarditis.
Teaching Points:
- During the work-up, we learned that this patient had a bioprosthetic aortic valve. During our discussion, we reviewed American College of Cardiology indications for thrombosis prophylaxis in valve replacement. A summary of this can be seen in table 1.
- Remember that any valve replacement surgery increases risk for endocarditis. Other features that increase risk include history of IV drug use, valvular heart disease, congenital heart disease, or previous history of endocarditis.
- When evaluating acute fever in a newly admitted patient, think common things first, ie infection. Follow where the signs/symptoms lead you. For example if the patient has...
---->headaches, neck stiffness, confusion, headache: Think meningitis
---->cough, sputum, dyspnea: Think pneumonia
---->diarrhea, abdominal pain: Think enteritis, diverticulitis, or c diff colitis
---->dysuria, hematuria, flank pain: Think pyelonephritis, cystitis
---->right upper quadrant pain, jaundice: Think cholangitis
^These signs and symptoms are not hard in fast rules for presentations of these illnesses but should help guide your infectious work-up. All infectious work-ups should include...
---->Basic chem +/- CMP
---->CBC with differential
---->Blood cultures
---->Lactic acid if concerned for sepsis
---->And probably a chest x-ray, UA, and ECG
- Dario also discussed antibacterial prophylaxis for endocarditis. See table 2 for indications for antibacterial prophylaxis.
- Remember, most common regimen for prophylaxis is amoxicillin 2g 30-60 minutes prior to procedure.
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