These pathlets are edutainment. This site collects no information about visitors, and cannot substitute for your own doctor's care. It has some questions without clear right-or-wrong answers. Scripting by Ed Friedlander MD.
He is pale, dyspneic, and diaphoretic.
Temperature is 101.9 F, pulse 110, respirations 25, blood pressure 140/60.
He is slender and has many tattoos.
Some of these cover track marks of intravenous drug use.
The neck veins indicate a central venous pressure around 12 cm, and the A and C waves
are visible but not expecially prominent The lungs contain crackles over all lobes.
Click HERE to hear his early diastolic murmur. It is a high-pitched decrescendo murmur that does not vary with respiration.(courtesy of Dr. Eric Strong)
What's the murmur?
Aortic valve insufficiency (regurgitation)
Aortic valve stenosis
Mitral valve insufficiency (regurgitation)
Mitral valve stenosis
Pulmonic valve insufficiency (regurgitation)
Pulmonic valve stenosis
Tricuspid valve insufficiency (regurgitation)
Tricuspid valve stenosis
Pictures courtesy of Charles Goldberg MD
To the left are two photos of the patient's hands.
Based just on the history and physical exam, what likelihood would you assign each of the following?
The diagnosis of BACTERIAL ENDOCARDITIS involving the aortic valve is
strongly supported by the murmur, the history of IV drug use, the fever,
the evidence of heart failure, and the hand findings. We trust you recognized the
Osler nodes (top) and Janeway lesions (bottom). But one of the hazards of medicine is
getting tunnel vision when the diagnosis seems obvious.
The patient is actually complaining about a headache, so there must be something
going on in the head as well. We want to rule in-or-out both
BACTERIAL MENINGITIS and a SUBARACHNOID HEMORRHAGE. We may get imaging and perhaps
a lumbar puncture.
There are other possibilities which might in combination
give this picture.
When aortic valve regurgitation is discovered, it's important to think of an AORTIC
DISSECTION. Since missing this is a catastrophe, it's a consideration and imaging may
need to be undertaken.
SYPHILIS was once the most common cause of aortic regurgitation, and is still with us.
DELIRIUM TREMENS might be a consideration, though not a complete explanation for
A community-acquired BACTERIAL PNEUMONIA may make a person confused, febrile, and short
of breath. It's worth inclusing in the differntial diagnosis.
Recent exercise, asthma, Kaposi's, emphysema and viral pneumonitis seem unlikely.
TUBERCULOSIS, though, is a good thought. Drug abusers, especially with HIV, may bring
tuberculosis into the hospital, and he does have a fever.
There is no scar from old heart surgery, but without a history, it would be a shame to miss
a candida or aspergillus infection on a prosthetic heart valve, causing it to leak.
So if you thought of a fungal infection, that's a good thing.
... admit to the hospital
... CBC with differential, look at the smear yourself
... electrolytes and chemical profile
... chest x-ray
... sputum for gram stain and culture
... sputum for acid-fast bacilli
... CT scan of the head
... if the CT of the head shows no space-occupying lesion, lumbar puncture
... blood cultures
... point-of-care HIV test
... applied a tuberculin skin test with controls for anergy
... arrange for an ultrasound of the heart
Unfortunately, the patient died on his way to the CT scan. CPR failed.
At autopsy, a ruptured mycotic aneurysm at the origin of the right middle cerebral aneurysm
was found. Here are the mitral and aortic valves.
What is your diagnosis now?
Acute rheumatic fever
Bacterial endocarditis on previously normal valves
Bacterial endocarditis on valves damaged by old rheumatic fever
Bacterial endocarditis on a bicuspid aortic valve and a Barlow mitral valve
None of the above.
Photos courtesy of Tracy Taylor Ph.D.
We hope you recognized the red-brown bacterial vegetations on otherwise-normal valves.
The day after the autopsy, the lab phones and invites you to look at the microbes
that grew from the patient's blood.
Here are the catalase and coagulase tests. The control for the coagulase is the bottom tube.
What do they tell you is the pathogen?
Something in the HACEK group
This man could not have been saved. The bacteria turned out to be the aggressive "MRSA" strain,
and a septic embolus produced a mycotic aneurysm that ruptured. This case is a reminder that
bacterial endocarditis is still very much with us.
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