A 61-year-old male patient presented to the emergency room (ER) on account of a 3-month history of hemoptysis as well as a 2-week history of right upper extremity weakness and numbness.
Hemoptysis was associated with pleuritic right-sided chest pain as well as orthopnea and had been previously treated with two courses of empiric antibiotics and steroids at an outside hospital without improvement prompting his presentation to our emergency room.
Weakness and numbness of the right upper extremity were initially associated with a painful right palmar rash which was resolved with self-administered topical corticosteroids at home.
Past medical history was significant for untreated latent tuberculosis (TB) diagnosed about forty years prior to this presentation as well as coronary artery disease requiring stent placement twice in the past.
On presentation, the patient was not in acute distress but was tachycardic at 100 beats per minute, with a respiratory rate of 16 cycles per minute and an oxygen saturation of 100 percent on room air. Blood pressure was 144/87 millimeters of mercury, and temperature was 99 degrees Fahrenheit.
On physical examination, he was afebrile and had normal breath sounds and heart sounds without murmurs. Neurological examination was notable for reduced sensation to light but not crude touch over the right hand with reduced strength of 4/5 in that in same extremity. Laboratory studies were significant for a white blood cell count of 18,400 per microliter with 76.3 percent neutrophils, an erythrocyte sedimentation rate of 90 millimeters per hour, and a C-reactive protein level of 167 milligrams per liter.
Imaging done on admission revealed multifocal lung opacities (Figure 1) concerning for community-acquired multifocal pneumonia (possibly secondary to a resistant organism as patient had completed courses of cefdinir and levofloxacin at the outside hospital without resolution of his symptoms). Other considerations were for possible septic emboli of undetermined source as well as reactivated pulmonary tuberculosis given his long-standing history of latent TB with multiple positive skin purified protein derivative tests in the past.
CT scan of the head without contrast was concerning for a possible infarct of unclear age, and a follow-up MRI revealed possible abscess collection (Figures 2 and 3).
He was initially placed on airborne isolation with empiric first-line antituberculosis agents (which were discontinued after 6 negative acid-fast bacilli sputum samples were obtained) as well as empiric antibiotics (vancomycin and piperacillin/tazobactam) for possible multifocal pneumonia, based on recommendations of the infectious disease consultants. Two blood cultures, obtained on admission, returned positive and grew Streptococcus intermedius sensitive to ceftriaxone, levofloxacin, tetracycline, erythromycin, clindamycin, and vancomycin. A transthoracic echocardiogram showed normal left ventricular systolic function and normal valves without regurgitations, stenosis or, vegetations.
A subsequent transesophageal echocardiogram (TEE) revealed an 8.3 x 4.6 mm oscillating dumbbell-shaped vegetation arising from the Chiari network, close to the os of the right atrial appendage (Figure 4), without evidence of valvular vegetations, insufficiency, or a patent foramen ovale.
A diagnosis of infective endocarditis was made based on the modified Duke criteria with two separate blood cultures positive for Streptococcus intermedius, echocardiographic findings of an oscillating intracardiac mass, consistent with a vegetation, and septic pulmonary and intracranial lesions. Medical management was chosen at the time of the diagnosis of this Chiari network endocarditis with septic emboli to the lungs and brain, with plans for repeat imaging with a transesophageal echo after six weeks of appropriate antibiotic therapy.
Antibiotic coverage was thus narrowed and tailored to the culprit organism with ceftriaxone, and gentamycin was added for endocarditis synergy per infectious disease team recommendations. Clinical and laboratory evidences of improvement including resolution of the hemoptysis and right upper extremity weakness as well as reduction in the white blood cell count from 18,400 per microliter on admission to 6400 per microliter and in the erythrocyte sedimentation rate from 90 millimeters per hour to 28 millimeters per hour as well as the C reactive protein from 167 milligrams per liter to 0.9 milligrams per liter were documented.
Interval reduction in the size of the lung lesions but not the brain lesions was noted after four weeks of parenteral antibiotic treatment, and neurosurgical evaluation for possible evacuation of the abscess was thus recommended. The patient was transferred to an outside hospital where those services were readily available. He had an image-guided stereotactic drainage of the abscess via a left parietal burr hole, with initial gram stain of the fluid showing gram-positive cocci, but the culture had no growth after 5 days probably because the patient had been on appropriate antibiotics for four weeks prior to the drainage procedure.
The patient completed six weeks of antibiotic therapy at the outside hospital and was discharged home in a stable clinical state but did not follow up as recommended.