Dr.Venkatesh Kumar, Dr.R.Krishna Kumar(Paed cardio) Dr.Vinitha Prasad,Dr.Stefy,Dr.Shela,Dr.C.Jayakumar,AIMS Kochi.
Eleven year old male child – K/C/O Restrictive perimembranous VSD presented with recurrent fever of 1 ½ month duration requiring two hospital admissions in the past 1 month.For the first admission,he was treated as a urinary tract infection with antibiotics for 7 days,child became afebrile then discharged.He was admitted one week later with Frontal sinusitis and was treated with inj Cefazolin for 10 days.He was now admitted with fever of 5 days duration in AIMS,Pediatrics.
He had white tonsillar patch with splenomegaly.
Throat swab for culture revealed MRSA growth.
Other PUO workup done was negative.
Suspecting Infective endocarditis,Blood C/S sent as per Infective endocarditis protocol was negative.
Echocardiography was done and was found to have no definite evidence of Infective endocarditis but a bright opacity in the tip of septal tricuspid leaflet with restrictive perimembranous VSD and that restricted septal tricuspid leaflet. He was treated with Inj.Vancomycin and was afebrile for 4 days,hence discharged.
He was admitted again after 1 week later with fever and generalised body-ache of 1 day duration.
This time also blood culture was sent as per I.E.protocol.
General examination was within normal limits.
Auxology revealed normal growth parameters.
Systemic examination showed grade IV pan- systolic murmur best heard in the left lower sternal border.
Differential diagnosis considered were:
1. Infective endocarditis
2. Infections- TB,HIV,Malaria,Enteric fever
3. SLE- Libmann sach’s endocarditis
4. Cardiac neoplasms-Atrial myxomas.
5. Immunodeficiency
6. Lyme disease
7.Tricuspid regurgitation
INVESTIGATIONS:
Haemogram: TC-6.74 ku/ml, N-54.5%,L-35.5%,Hb-11.7 g/dl,Plt-306 ku/ml,ESR- 19 mm/1st hr
LFT: SGOT- 17.1 IU/L, SGPT-12.7 IU/L,ALP-161 IU/L,T.protein-7 gm/dl,S.Albumin-4 gm/dl,S.globulin-3 gm/dl,TB-0.2 mg/dl,DB-0.1 mg/dl
RFT: Urea-22.9 mg/dl, Creatinine- 0.47 mg/dl
S.Electrolytes: Na+:138.9 mEq/L, K+:4.2 mEq/L
CRP: 3.04 mg/L
Peripheral blood smear:Normocytic normochromic anemia with thrombocytosis.
ANA: Negative
Brucella IgM: Negative, Leptospira IgM: Negative, Salmonella antibody: Negative
Blood Culture(according to I.E.protocol-3 cultures sent):2 out of 3 cultures showed growth of Streptococcus sanguis(S.viridans)
ECHO: Bright opacity in the tip of septal tricuspid leaflet,Restrictive perimembranous VSD restricted septal tricuspid leaflet,Inter- ventricular gradient 72 mm Hg,No LVOTO/RVOTO,Biventricular function –normal.
Impression: Possible infective endocarditis( 1 major + 2 minor criteria)
Major criteria:
Streptococcus sanguis isolated from 2 out of 3 cultures.
? Vegetation over tricuspid leaflet.
Minor criteria:
Predisposition-CHD(Perimembranous VSD).
Fever.
He was then given Inj.Ceftraixone 2 gm IV OD for 6 weeks and Inj.Gentamicin 100 mg IV OD for 2 weeks.
With this child became afebrile and on follow up.
Discussion:
Infective Endocarditis (IE):
Modified Duke Criteria-
Definite Infective Endocarditis
Pathologic Criteria:
• Microorganisms demonstrated results of cultures or histologic examination of a vegetation,
A vegetation that has embolized
an Intra cardiac abscess specimen; or
• Pathologic lesions; vegetation, or Intracardiac abscess confirmed results of histologic examination showing active endocarditis
Clinical Criteria:
• 2 major criteria, or
• 1 major criterion and 3 minor criteria, or
• 5 minor criteria
Possible Infective Endocarditis :
• 1 major criterion and 1 minor criterion, or
• 3 minor criteria
Rejected Diagnosis of Infective Endocarditis :
• Firm alternate diagnosis explaining evidence of suspected IE, or
• Resolution of IE syndrome with antibiotic therapy for ≤4 days, or
• No evidence of IE at surgery or autopsy, on antibiotic therapy for ≤4 days, or
• Does not meet criteria for possible IE
Definition of Terms Used in Modified Duke Criteria Major Criteria :
1. Blood culture findings positive for IE Typical microorganisms consistent with IE from 2 separate blood cultures:
• Viridans streptococci, Streptococcus gallolyticus(formerly known as S. bovis ), Staphylococcus aureus, HACEK group, or
• Community-acquired enterococci, in the absence of a primary focus, or
Microorganisms consistent with IE from persistently positive blood culture findings, defined as:
• ≥2 positive culture findings of blood samples drawn >12 hr apart, or
• 3 or most of ≥4 separate culture findings of blood (with first and last sample drawn ≥1 hr apart)
• Single positive blood culture for Coxiella burnetii or anti– phase I lgG titer ≥1 : 800
2. Evidence of endocardial involvement Echocardiographic findings positive for IE (Trans oesophageal echocardiogram cardiography recommended in patients with prosthetic valves, rated at least possible IE clinical criteria or complicated IE [paravalvular abscess]; TTE as 1st test in other patients), defined as follows:
• Oscillating intracardiac mass on 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 New valvular regurgitation; worsening or changing of preexisting murmur.
Minor Criteria :
• Predisposition, predisposing heart condition, or intravenous drug use
• Fever—temperature >38°C
• Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
• Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
• Microbiologic evidence: positive blood culture finding but does not meet a major criterion as noted above (excludes single positive culture findings for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of active infection with organism consistent with IE.
Carry home message:In any case of PUO,infective endocarditis should be considered as a differential diagnosis and should be ruled out doing Echocardiography and blood cultures.