MR with Nishant + Dr. Kim: Leukocytoclastic Vasculitis and Endocarditis

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) [1].

-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:

9/14 Wednesday AM with Shawn: Endocarditis

An elderly woman with a pmh of moderate AS and a R TKA 5 years prior who initially presented to her PCP with R knee pain.  She was initially treated with a steroid injection as well as a course of PO prednisone.   Several weeks later she continued to have knee pain and was seen by ortho – arthrocentesis at that time revealed a WBC of 25K and culture grew out Step Milleri – she was started on antibiotics.  Plans were made for a 2 step knee replacement.  During pre-op workup, she was noted to be in atrial fibrillation. She was subsequently sent home with an event monitor and was called back to the ED after it detected 3^rd degree heart block.  Subsequent ECHO demonstrated perivalvular abscess involving the aortic valve.  Unfortunately, she was deemed too high risk for surgery, and was sent home on hospice with plans for comfort care.

Learning Points

-Pay attention to surgical history – the presence of hardware in this patient’s knee increased her risk of septic arthritis

-TTE sensitivity for vegetation is 75% compared with sensitivity of TEE which is > 90%

-Heart block should raise suspicions for perivalvular abscess, specifically involving the aortic valve

Duke’s criteria for endocarditis:

Criteria for Diagnosis: 2 Major; 1 Major and 3 Minor; 0 Major and 5 Minor

Major

1)       + Blood Cx for typical infective endocarditis organisms (S. Viridans or Bovis; HACEK, S. Aureus) from 2 separate blood cultures or 2 positive cultures from samples drawn > 12 hrs apart

2)       Echo with oscillating intracardiac mass or valve or supporting structures in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic valve or new valvular regurgitation

Minor

1)       Predisposing heart condition or IV drug use

2)       Temp > 38

3)       Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions

4)       Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots; RF

5)       Microbiological evidence: positive blood Cx but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with endocarditis (excluding coag neg staph, and other common contaminants)

6)       Echo findings: consistent with endocarditis but do not meet a major criterion as noted above