Pathlet 004
Gabe Randall KCUMB '15

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.

Ernst Kirchner, 1918
Self-Portrait as a Sick Man
A 31-year-old man is dropped off on the steps of the emergency room. He is confused, and says "My head! My head, man! No!" You cannot get any more history.

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

Good! You recognized the murmur of aortic insufficiency / regurgitation.

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?

ACUTE RHEUMATIC FEVER: Very Unlikely               Very Likely
AORTIC DISSECTION: Very Unlikely               Very Likely
ASTHMA: Very Unlikely               Very Likely
BACTERIAL ENDOCARDITIS: Very Unlikely               Very Likely
BACTERIAL MENINGITIS: Very Unlikely               Very Likely
COMMUNITY ACQUIRED PNEUMONIA: Very Unlikely               Very Likely
DELIRIUM TREMENS: Very Unlikely               Very Likely
EHLERS-DANLOS TYPE IV Very Unlikely               Very Likely
EMPHYSEMA: Very Unlikely               Very Likely
KAPOSI SARCOMA: Very Unlikely               Very Likely
LIBMAN-SACKS ENDOCARDITIS: Very Unlikely               Very Likely
RECENT EXCESSIVE EXERCISE: Very Unlikely               Very Likely
SUBARACHNOID HEMORRHAGE: Very Unlikely               Very Likely
SYSTEMIC FUNGAL INFECTION: Very Unlikely               Very Likely
TERTIARY SYPHILIS: Very Unlikely               Very Likely
TUBERCULOSIS: Very Unlikely               Very Likely
VIRAL PNEUMONITIS: Very Unlikely               Very Likely

Different physicians will give you somewhat different estimates. These are just ours.

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 his presentation.

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.

You wisely decide that this patient needs more than just some rest. What will you do now?

... admit to the hospital
... CBC with differential, look at the smear yourself
... electrolytes and chemical profile
... electrocardiogram
... chest x-ray
... electrocardiogram
... urinalysis
... 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

Douglas Manry, "Hospital at 4 AM"

You probably decided to do all of these.

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?

Coagulase-positive staphylococcus
Coagulase-negative staphylococcis
Something in the HACEK group

Good! This is a coagulase-positive staphlococcus. You recognized the bubbly positive catalase test, and the cloudy positive coagulase test in the top tube.

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.

Gabe Randall

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