A middle aged man presents with 6 days of severe myalgias, low grade fevers, and rash. He initially underwent a broad work-up for his rash including infectious and autoimmune etiologies; his blood cultures ultimately grew staph aureus and TEE showed new severe AI and an aortic vegetation.
1. Endocarditis can present in very atypical ways – in an unknown inflammatory condition, it is on the differential!
2. Staph Aureus is BAD
– This patient subsequently found to have septic cerebral emboli
– IE due to Staphylococcus aureus is associated with complications more frequently than other pathogens (stroke 21 versus 14 percent, systemic emboli 27 versus 18 percent, persistent bacteremia 17 versus 5 percent, and in-hospital mortality 22 versus 14 percent) .
-Staph aureus infection is itself a criteria for surgical repair of left-sided endocarditis. See this excellent algorithm to decide who gets surgery: https://www.uptodate.com/contents/image?imageKey=CARD%2F54251&topicKey=CARD%2F2148&rank=1~150&source=see_link&search=surgical%20indications%20for%20endocarditis
3. Leukocytoclastic vasculitis (i.e. the histologic correlate to ‘palpable purpura’) is classically associated with HSP but actually can result from many etiologies (in this case, the patient’s lesions may have been a combination of septic emboli and true immunologic complex lesions)
– think big categories of vasculitis, chronic infections, and medications
– one rheum attending uses complement levels for the initial branch point: