CLINICAL COMMUNICATION TO THE EDITOR
Afebrile Endocarditis Presenting as Purpura and Acute Renal Failure To the Editor: Infective endocarditis is a disease of high morbidity and mortality. One difficulty encountered in endocarditis diagnosis is related to the fact that some classic clinical manifestations may be absent. We describe a 74-year-old patient admitted to our department with new-onset purpuric leg rash and acute renal failure. He was initially thought to have Henoch-Schönlein purpura but was eventually diagnosed with Streptococcus viridans endocarditis. The diagnosis was confounded by the absence of fever at presentation and during hospitalization. Although the Duke criteria are the reference criteria for endocarditis diagnosis, they should not replace clinical judgment for diagnosis in the individual patient, especially in the first stage of care.1
CASE REPORT
sanguinis (viridans) in 3 blood cultures. Transesophageal echocardiography demonstrated large vegetations on the aortic valve, with new regurgitation. Intravenous ceftriaxone treatment was administered to the patient. Because of abscess formation on follow-up echocardiography after 6 days of treatment, urgent valve replacement was performed. The patient’s condition improved, and his purpuric rash disappeared together with normalization of complement levels.
DISCUSSION Infective endocarditis can present insidiously with seemingly nonspecific symptoms.2 The diagnosis is based on clinical, microbiologic, and echocardiographic findings.1 Fever is common, occurring in up to 96% of cases. If a patient does not have fever, however, clinicians frequently do not consider this diagnosis. Case reports of afebrile endocarditis are scarce. Teich3 described 2 cases of afebrile bacterial endocarditis in 1968. He concluded that although fever is the most common clinical finding in endocarditis, its absence should not mislead the clinician to discard this diagnosis and even recommended obtaining
A 74-year-old previously healthy man, except for known moderate aortic stenosis and hypertension, was referred to our hospital because of a new rash on his legs. Detailed anamnesis revealed weakness and weight loss in the last few weeks, without fever or other specific symptoms. Examination demonstrated purpuric rash on both legs (Figure 1). Initial clinical evaluation revealed borderline increased inflammatory markers, acute renal failure (creatinine, 1.8 mg/dL), and a urine dipstick positive for protein and blood, without red blood cells casts on urine microscopy. Henoch-Schönlein purpura was the working diagnosis given the combination of rash, elevated creatinine, and dipstick findings. Hypocomplementemia was noticed. Biopsy of the skin lesion demonstrated perivascular infiltration, without complement or immunoglobulin-A depositions. Blood cultures, taken because of suggested long-duration symptoms, known valvular disease, purpuric rash, and low complement levels, grew Streptococcus Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Gil Lavie, MD, MHA, Sho’ham Street 15A, Haifa, Israel 3467922. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Figure 1
Purpuric leg rash
e6 blood cultures in all patients with organic cardiac murmurs who display any unexplained findings.3 A complete dermatologic physical examination is essential for the diagnosis of endocarditis and may have a prognostic role. The presence of cutaneous lesions should alert physicians to look for secondary complications, notably with cerebral imaging.4 Purpura is found in 8% of endocarditis cases and is associated with larger cardiac vegetations and higher risk of cerebral embolic events.4 Most patients with endocarditis have an abnormal urinalysis. Renal manifestations can range from microscopic hematuria to acute kidney injury.2 Renal failure is a rare complication of endocarditis. The main mechanism is widely accepted to be immune complexemediated glomerulonephritis, although renal embolization and abscess have been reported as possible causes.
The American Journal of Medicine, Vol 128, No 3, March 2015 Gil Lavie, MD, MHAa,d Oryan Henig, MDb Gabriel Weber, MDb,d Amnon Y. Zlotnick, MDc Shai Cohen, MDa,d a
Division of Internal Medicine Lady Davis Carmel Medical Center Haifa, Israel b Infectious Disease Unit Lady Davis Carmel Medical Center Haifa, Israel c The Department of Cardiothoracic Surgery Lady Davis Carmel Medical Center Haifa, Israel d Ruth and Bruce Rappaport Faculty of Medicine Technion e Israel Institute of Technology Haifa, Israel
http://dx.doi.org/10.1016/j.amjmed.2014.10.028
CONCLUSIONS
References
The Duke criteria (eg, positive blood culture or positive endocardial involvement) are not usable on admission to identify patients at high risk of endocarditis because they can be fulfilled only after several days of investigation. Because prognosis is related to the prompt institution of antibiotic therapy, a high index of suspicion must be maintained, even in atypical afebrile presentation.
1. Hoen B, Duval X. Infective endocarditis. N Engl J Med. 2013;369:785. 2. Natarajan A, Hindocha D, Kular N, Fergey S, Davis JR. Vasculitic rash: do not jump to conclusions. Clin Med. 2012;12:179-180. 3. Teich EM. Afebrile bacterial endocarditis. A clinical study of two cases. J Mt Sinai Hosp N Y. 1968;35:566-577. 4. Servy A, Valeyrie-Allanore L, Alla F, et al. Prognostic value of skin manifestations of infective endocarditis. JAMA Dermatol. 2014;150: 494-500.
Afebrile Endocarditis Presenting as Purpura and Acute Renal Failure To the Editor: Infective endocarditis is a disease of high morbidity and mortality. One difficulty encountered in endocarditis diagnosis is related to the fact that some classic clinical manifestations may be absent. We describe a 74-year-old patient admitted to our department with new-onset purpuric leg rash and acute renal failure. He was initially thought to have Henoch-Schönlein purpura but was eventually diagnosed with Streptococcus viridans endocarditis. The diagnosis was confounded by the absence of fever at presentation and during hospitalization. Although the Duke criteria are the reference criteria for endocarditis diagnosis, they should not replace clinical judgment for diagnosis in the individual patient, especially in the first stage of care.1
CASE REPORT
sanguinis (viridans) in 3 blood cultures. Transesophageal echocardiography demonstrated large vegetations on the aortic valve, with new regurgitation. Intravenous ceftriaxone treatment was administered to the patient. Because of abscess formation on follow-up echocardiography after 6 days of treatment, urgent valve replacement was performed. The patient’s condition improved, and his purpuric rash disappeared together with normalization of complement levels.
DISCUSSION Infective endocarditis can present insidiously with seemingly nonspecific symptoms.2 The diagnosis is based on clinical, microbiologic, and echocardiographic findings.1 Fever is common, occurring in up to 96% of cases. If a patient does not have fever, however, clinicians frequently do not consider this diagnosis. Case reports of afebrile endocarditis are scarce. Teich3 described 2 cases of afebrile bacterial endocarditis in 1968. He concluded that although fever is the most common clinical finding in endocarditis, its absence should not mislead the clinician to discard this diagnosis and even recommended obtaining
A 74-year-old previously healthy man, except for known moderate aortic stenosis and hypertension, was referred to our hospital because of a new rash on his legs. Detailed anamnesis revealed weakness and weight loss in the last few weeks, without fever or other specific symptoms. Examination demonstrated purpuric rash on both legs (Figure 1). Initial clinical evaluation revealed borderline increased inflammatory markers, acute renal failure (creatinine, 1.8 mg/dL), and a urine dipstick positive for protein and blood, without red blood cells casts on urine microscopy. Henoch-Schönlein purpura was the working diagnosis given the combination of rash, elevated creatinine, and dipstick findings. Hypocomplementemia was noticed. Biopsy of the skin lesion demonstrated perivascular infiltration, without complement or immunoglobulin-A depositions. Blood cultures, taken because of suggested long-duration symptoms, known valvular disease, purpuric rash, and low complement levels, grew Streptococcus Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Gil Lavie, MD, MHA, Sho’ham Street 15A, Haifa, Israel 3467922. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Figure 1
Purpuric leg rash
e6 blood cultures in all patients with organic cardiac murmurs who display any unexplained findings.3 A complete dermatologic physical examination is essential for the diagnosis of endocarditis and may have a prognostic role. The presence of cutaneous lesions should alert physicians to look for secondary complications, notably with cerebral imaging.4 Purpura is found in 8% of endocarditis cases and is associated with larger cardiac vegetations and higher risk of cerebral embolic events.4 Most patients with endocarditis have an abnormal urinalysis. Renal manifestations can range from microscopic hematuria to acute kidney injury.2 Renal failure is a rare complication of endocarditis. The main mechanism is widely accepted to be immune complexemediated glomerulonephritis, although renal embolization and abscess have been reported as possible causes.
The American Journal of Medicine, Vol 128, No 3, March 2015 Gil Lavie, MD, MHAa,d Oryan Henig, MDb Gabriel Weber, MDb,d Amnon Y. Zlotnick, MDc Shai Cohen, MDa,d a
Division of Internal Medicine Lady Davis Carmel Medical Center Haifa, Israel b Infectious Disease Unit Lady Davis Carmel Medical Center Haifa, Israel c The Department of Cardiothoracic Surgery Lady Davis Carmel Medical Center Haifa, Israel d Ruth and Bruce Rappaport Faculty of Medicine Technion e Israel Institute of Technology Haifa, Israel
http://dx.doi.org/10.1016/j.amjmed.2014.10.028
CONCLUSIONS
References
The Duke criteria (eg, positive blood culture or positive endocardial involvement) are not usable on admission to identify patients at high risk of endocarditis because they can be fulfilled only after several days of investigation. Because prognosis is related to the prompt institution of antibiotic therapy, a high index of suspicion must be maintained, even in atypical afebrile presentation.
1. Hoen B, Duval X. Infective endocarditis. N Engl J Med. 2013;369:785. 2. Natarajan A, Hindocha D, Kular N, Fergey S, Davis JR. Vasculitic rash: do not jump to conclusions. Clin Med. 2012;12:179-180. 3. Teich EM. Afebrile bacterial endocarditis. A clinical study of two cases. J Mt Sinai Hosp N Y. 1968;35:566-577. 4. Servy A, Valeyrie-Allanore L, Alla F, et al. Prognostic value of skin manifestations of infective endocarditis. JAMA Dermatol. 2014;150: 494-500.
