OCCULT SEPTIC EMBOLISM: A CARDIOVASCULAR SHOWER TO THE BRAIN

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Left-sided infective endocarditis (IE) is a condition prevalent among patients with indwelling catheters. Once vegetation has been established, the infected valve's embolizing septic products migrate towards systemic circulation, potentially disrupting brain parenchyma's normal architecture [1]. CASE PRESENTATION: A 79-year-old female history of end-stage renal disease on hemodialysis and morbid obesity presented dysuria low blood pressure. Examination showed hypotension tachycardia. Work-up revealed leukocytosis bandemia. The urinalysis was infectious, chest x-ray consolidation in left lower lobe. IV fluids broad-spectrum antibiotics were immediately started mild clinical improvement. Urine cultures Staphylococcus aureus, Proteus mirabilis, Escherichia coli. Blood grew S. aureus. patient's had improved after two days treatment, but her pressure remained critically low, requiring vasopressors. Even though dialysis catheter replaced, suspicion for IE imperative. Transthoracic echocardiogram (TTE) an ejection fraction 60% no obvious vegetations. Transesophageal (TEE) non-oscillating mass aortic valve, suspicious Shortly afterward, patient developed progressive altered mental status without focal neurological deficits or seizures. diffusion-weighted magnetic resonance imaging displayed multiple foci diffusion restriction cerebrum, pons, cerebellum bilaterally. Additionally, corresponding apparent coefficient observed, consistent ischemia. Further workup lesions levels carbon monoxide, anion gap, glucose, ammonia. Unfortunately, became hypotensive, bradycardic, unresponsive during session expired thereafter. DISCUSSION: might prove challenging diagnosis when potential confounders entangle initial assessment. This different sources infection that explained findings. Prompt paramount there's lack improvement optimal medical therapy. TTE evidence but, morbidly obese patient, this isn't irregular finding. Therefore, TEE key population [2]. Moreover, even active embolization indication surgical evaluation, comorbidities personal wishes withheld further interventions [3]. CONCLUSIONS: IE's mortality can be up to 40% some cases complications worsen survival probabilities. Single tests may equivocal so combination findings diagnostic studies recommended. evaluation lifesaving cardiovascular shower ensued. REFERENCE #1: García-Cabrera E, Fernández-Hidalgo N, Almirante B, Ivanova-Georgieva R, Noureddine M, Plata et al. Neurological endocarditis: risk factors, outcome, impact cardiac surgery: multicenter observational study. Circulation 2013;127:2272–84. #2: Durack DT, Lukes AS, Bright DK. New criteria utilization specific echocardiographic Duke Endocarditis Service. Am J Med. 1994 Mar;96(3):200-9. doi: 10.1016/0002-9343(94)90143-0. PMID: 8154507 #3: ESC Scientific Document Group, 2015 Guidelines management Task Force Management Infective European Society Cardiology (ESC). Heart Journal, Volume 36, Issue 44, 21 November 2015, Pages 3075–3128, https://doi.org/10.1093/eurheartj/ehv319. DISCLOSURES: No relevant relationships by Abdul Rahman Al Armashi, source=Web Response Keyvan Ravakhah, Francisco Somoza-Cano, disclosure file Deema Chakhachiro