Transcript Document

Abdominal angina as the presenting symptom in
bacterial endocarditis.
Daniel Suders DO, Tom Waltz DO, Adel Frenn MD, Demetrio Agcaoili MD
Ohio Valley Medical Center
Case
This is a 61 year old male who presented with
50 pound weight loss over five months,
abdominal pain, poor oral intake, general
fatigue and malaise. Abdominal pain was
described as intermittent cramping pain, it was
worse with eating, which lead to his poor
appetite and weight loss.
Prior work-up for this complaint by
Gastroenterology included EGD and HIDA
scan. These tests showed Barrett’s esophagus
and biliary dyskinesia. He was sent to a
surgeon and underwent cholecystectomy.
Pathology showed chronic cholecystitis, but
after recovery from surgery, his symptoms were
unchanged. Upon questioning, he did relate
some dental work followed by a sinus infection
prior to the start of his abdominal symptoms.
Past medical history included CAD, atrial
fibrillation, HTN, and hyperlipidemia.
Case
The patient was admitted and found to suffer
from acute renal failure, acute anemia, and
hemoccult positive stools. A colonoscopy was
performed and showed evidence of ischemic
colitis. Blood cultures returned positive for
alpha streptococcus. Echocardiogram showed
an aortic valve vegetation, and TEE confirmed
an intravalvular abscess between the aortic
and mitral valves. The size of the vegetation
was estimated at 3x3 cm. He was treated with
IV Rocephin and Vancomycin. The cardiac
surgeons at our center were uncomfortable
with the complexity of the surgery he would
need, and recommended transfer to a tertiary
center. He was transferred to Cleveland Clinic,
where he underwent debridement and
replacement of the aortic valve, mitral valve
and intervalvular fibrosa. This surgery in itself
is relatively rare, and has only been performed
since 1997. In the end, he did well, and was
able to be discharged to home.
Discussion
While the symptoms the patient was
experiencing are common to subacute
endocarditis, this diagnosis was not considered
for many months. He exhibited several of the
Duke’s minor criteria, including fever, renal
failure suspected to be secondary to
glomerulonephritis, and evidence of major
arterial emboli. Of course, the diagnosis of
endocarditis was definitive after the positive
blood cultures and obvious vegetation on TEE.
Poster Presentation by Daniel J Suders DO
Conclusion
Endocarditis is a relatively uncommon cause of
febrile illness, but blood cultures should be
sampled in any febrile illness, particularly once
it becomes protracted. Abdominal pain,
mesenteric ischemia, and renal failure are all
possible presenting symptoms of embolic
endocarditis, though less common than
neurologic changes or pulmonary emboli.
Of note, no one on the case appreciated a heart
murmur, despite the large size of the vegetation.
Some of the more commonly seen embolic
phenomena in endocarditis include neurological
symptoms, secondary to cerebral septic emboli
and pulmonary infarcts secondary to septic
emboli to the lungs. This patient did not show
signs of either, but was found to have ischemic
colitis, suspected to be secondary to septic
emboli to the mesenteric arteries. While this has
been documented in the literature, it is very rare.
We believe that the intermittent abdominal pain
that went on for months was likely caused by
intermittent embolic occlusion of the mesenteric
arterial system, causing abdominal angina.
The overall vagueness of his symptoms was a
challenge for everyone on the case. During his
long outpatient workup, a blood culture had
never been checked, despite continued
intermittent fevers. Even during the admission
where the diagnosis was made, it took a few
days to discover the true source of his
symptoms. During which some of the subspecialists were chasing down other causes of
his symptoms.
A good, thoughtful, osteopathic internist,
following the osteopathic tenets, should
consider the patient as a whole in a case like
this to make the appropriate diagnosis. We
often fall into the trap of containing the work up
to one organ or system, which did occur in this
case for some time. For example, this patient
had even underwent a cholecystectomy for
these abdominal symptoms, before the true
etiology was discovered. This also illustrates
the role of the internist as the informational
hub, which is essential to the coordination of
patient care.
This was an interesting and challenging case
that illustrates the importance of a thorough
history and physical and the need to consider
the patient as a whole.
Literature Cited:
1. Misawa, Sakano, et al. Septic embolic occlusion of SMA
induced by mitral valve endocarditis. Annals Thoracic
Cardiovascular Surgery 2011; Vol. 17, No. 4: 415-417
2. Double valve replacement and reconstruction of the
intravalvular fibrous body in patients with active infective
endocarditis. European Journal Cardiothoracic Surgery 2013.
3. Guler, Sokmen, et al. Infective endocarditis developing
serious multiple complications. BMJ Case Reports 2013:
doi:
10.1136/bcr-2012-008097.
4. Kim, Park, et al. Long-Term Results of Aortomitral Fibrous
Body Reconstruction With Double-Valve Replacement. Ann
Thorac Surg 2013;95: 635-641
ACOI Annual Convention and Scientific Sessions 2013