The SEPTIC CEREBRAL INFARCT COMPLICATED BY METHYCILLIN-RESISTANT COAGULASE-NEGATIVE STAPHYLOCOCCUS (MRCONS) ENDOCARDITIS, AIDED BY POINT-OF-CARE ULTRASOUND (POCUS): Case Report

Abstract

Introduction : The diagnosis of infective endocarditis (IE) in emergency department (ED) was crucial as it associated with significant morbidity and mortality. Often, the diagnosis was delayed due to varied presentations of IE and reliance on positive blood cultures and echocardiographic findings. The utilisation of point-of-care echocardioraphy in ED was rapid and can assist in immediate diagnosis and management of IE.

Case Presentation: A 22-year-old Malay gentleman with underlying end-stage renal disease, presented with acute left sided weakness associated with slurring of speech and fever for a day. Physical examination demonstrated temperature of 39 Celcius, grade 5/6 holo-systolic murmur over the apex, upper motor neuron lesion over left sided body with muscle power of 0/5, left facial asymmetry and left homonymous hemianopia. Computed tomography of brain revealed hypodensity over right lentiform nucleus.  Bedside echocardiography demonstrated severe mitral regurgitation and vegetation. Blood cultures showed methycillin-resistant coagulase negative Staphylococcus and he was put on six weeks of intravenous vancomycin. Upon discharge, his speech disturbance was improved and muscle power regained to 4/5. He was scheduled for outpatient cardiologist for subsequent management of IE.

Discussion : Cerebral embolism complicated up to 40 % of IE and was due to embolization of valvular vegetation. Blood cultures and echocardiogram were major diagnostic tests. Echocardiographic findings included valvular vegetation, peri-annular abscess, new valvular regurgitation or prosthethic valve dehiscence. The sensitivity and specificity of transthoracic echocardioraphy (TTE) for detecting IE on native valves were 65 % and 96 %,  but lower for prosthetic valves.  TTE was the initial modality to detect IE, followed by transesophageal echocardiography (TEE) for uncertainty cases with a high clinical suspicion.

Conclusion : Clinicians should be aware of varied presentations of IE and the accessibility of point-of-care echocardiography may expedite the diagnosis of IE by emergency physician, therefore treatment can be initiated early.