Case Study

A 37-year-old man was seen in the emergency department with a fever of ten days' duration associated with chills, rigors, sweats, headache, lethargy, and weakness. A Medtronic-Hall mechanical aortic valve prosthesis had been implanted 18 years previously. He had been asymptomatic until his present illness. At the time of appearance of fever (with temperatures to 103.9 °F.), he noted the sudden onset of pleuritic left upper quadrant pain and severe pain in the left posterior thigh. He had recently traveled to the Punjab without antimalarial prophylaxis. Coumadin was his only medication, and the anticoagulation level was in the therapeutic range. He had not been treated with antibiotics. The patient had a blood pressure of 90/71 with a regular heart rate of 98 beats per minute. There was no evidence of heart failure or pneumonia on examination or chest x-ray. He had no other symptoms to suggest a urinary or abdominal source of sepsis. Does this patient have endocarditis and what should be done for him?

The diagnosis of infective endocarditis (IE) can be a difficult one to make. Since the late 1970s attempts have been made to develop diagnostic criteria and algorithms to predict the presence of IE. Making the correct diagnosis is important for a number of reasons, including ensuring that antibiotic treatment is adequately prolonged, determining whether there is a need for surgical intervention, and confirming that another source of infection has not been missed.

In this chapter, we briefly review the history of IE leading to the current diagnostic approach, the existing stratagems for case definitions, and the utility of echocardiography in assisting with diagnosis. We also examine specific scenarios in which the diagnosis of IE may be particularly challenging.

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