Clinics and Practice 2012; volume 2:e1
Mild stroke symptoms as the initial presentation of a patient with underlying subacute bacterial endocarditis Ami Kamdar, Michael Debney, James Scott, Diane Ames Imperial College Healthcare NHS Trust, London, UK
Abstract We describe a patient with sub-acute bacterial endocarditis, whose chief presenting feature was mild expressive dysphasia.
Case Report A 68-year-old male presented to our hospital complaining of very mild word finding difficulties. He had instrumental dental cleaning four weeks previously. He had a background history of ischaemic heart disease, mitral valve repair (for mitral valve prolapse), hypertension and paroxysmal atrial fibrillation. On examination, he had a temperature of 37.9°, very subtle expressive dysphasia, left palmar erythema and a petechial rash on the left little finger pulps. He had raised inflammatory markers and blood cultures grew Enterococcus faecalis. His transthoracic echocardiogram revealed a 5¥4 mm vegetation of the anterior mitral valve leaflet (Figures 1 and 2). His brain magnetic resonance imaging (MRI) showed acute bilateral embolic infarcts (Figures 3 and 4). The patient was treated with six weeks of intravenous antibiotics (amoxicillin, vancomycin and gentamicin) for infective endocarditis. He responded well with falling inflammatory markers and reduction in vegetation size.
tic and therapeutic procedures, the mortality rate (9.6-26%) of IE has not changed in the last 30 years.1
References 1. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30;2369-413. 2. Thuny F, Di Salvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicentre study. Circulation 2005;112:69-75. 3. Lockhard PB. The risk of endocarditis in dental practice. Periodontol 2000;23:12735.
Correspondence: Dr Ami Kamdar, Department of Stroke Medicine, Charing Cross Hospital (Imperial College NHS Trust). Fulham Palace Rd, London. W6 8RF, UK. E-mail: [email protected] Key words: subacute bacterial endocarditis, embolic infarcts. Received for publication: 28 October 2011. Revision received: 29 November 2011. Accepted for publication: 30 November 0011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BYNC 3.0). ©Copyright A. Kamdar et al., 2012 Licensee PAGEPress, Italy Clinics and Practice 2012; 2:e1 doi:10.4081/cp.2012.e1
Figure 1. Parasternal long axis viewshowing vegetation on anterior mitral valve leaflet.
Figure 2. Parasternal short axis view showing vegetation on anterior mitral valve leaflet.
Figure 3. Magnetic resonance imaging head-DWI hyperintensity revealing a left temporo-parietal infarct.
Figure 4. Magnetic resonance imaging head-DWI hyperintensity in the right parietal cortex revealing an embolic infarct.
Discussion The epidemiology of infective endocarditis (IE) has changed substantially in the last few years in industrialised nations where the incidence increases with age (peak incidence 7080 years of age).1 In 30% of patients, embolization to the brain, lung or spleen is the presenting feature.2 The incidence of IE after dental procedures is highly variable and can range from 10-100%.3 Good oral hygiene and regular dental review is of importance for the prevention of IE. Despite major advances in diagnos-
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Mild stroke symptoms as the initial presentation of a patient with underlying subacute bacterial endocarditis Ami Kamdar, Michael Debney, James Scott, Diane Ames Imperial College Healthcare NHS Trust, London, UK
Abstract We describe a patient with sub-acute bacterial endocarditis, whose chief presenting feature was mild expressive dysphasia.
Case Report A 68-year-old male presented to our hospital complaining of very mild word finding difficulties. He had instrumental dental cleaning four weeks previously. He had a background history of ischaemic heart disease, mitral valve repair (for mitral valve prolapse), hypertension and paroxysmal atrial fibrillation. On examination, he had a temperature of 37.9°, very subtle expressive dysphasia, left palmar erythema and a petechial rash on the left little finger pulps. He had raised inflammatory markers and blood cultures grew Enterococcus faecalis. His transthoracic echocardiogram revealed a 5¥4 mm vegetation of the anterior mitral valve leaflet (Figures 1 and 2). His brain magnetic resonance imaging (MRI) showed acute bilateral embolic infarcts (Figures 3 and 4). The patient was treated with six weeks of intravenous antibiotics (amoxicillin, vancomycin and gentamicin) for infective endocarditis. He responded well with falling inflammatory markers and reduction in vegetation size.
tic and therapeutic procedures, the mortality rate (9.6-26%) of IE has not changed in the last 30 years.1
References 1. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30;2369-413. 2. Thuny F, Di Salvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicentre study. Circulation 2005;112:69-75. 3. Lockhard PB. The risk of endocarditis in dental practice. Periodontol 2000;23:12735.
Correspondence: Dr Ami Kamdar, Department of Stroke Medicine, Charing Cross Hospital (Imperial College NHS Trust). Fulham Palace Rd, London. W6 8RF, UK. E-mail: [email protected] Key words: subacute bacterial endocarditis, embolic infarcts. Received for publication: 28 October 2011. Revision received: 29 November 2011. Accepted for publication: 30 November 0011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BYNC 3.0). ©Copyright A. Kamdar et al., 2012 Licensee PAGEPress, Italy Clinics and Practice 2012; 2:e1 doi:10.4081/cp.2012.e1
Figure 1. Parasternal long axis viewshowing vegetation on anterior mitral valve leaflet.
Figure 2. Parasternal short axis view showing vegetation on anterior mitral valve leaflet.
Figure 3. Magnetic resonance imaging head-DWI hyperintensity revealing a left temporo-parietal infarct.
Figure 4. Magnetic resonance imaging head-DWI hyperintensity in the right parietal cortex revealing an embolic infarct.
Discussion The epidemiology of infective endocarditis (IE) has changed substantially in the last few years in industrialised nations where the incidence increases with age (peak incidence 7080 years of age).1 In 30% of patients, embolization to the brain, lung or spleen is the presenting feature.2 The incidence of IE after dental procedures is highly variable and can range from 10-100%.3 Good oral hygiene and regular dental review is of importance for the prevention of IE. Despite major advances in diagnos-
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