Case Study

Alfred Reinhart was born in 1907 with a brilliant mind. He contracted rheumatic fever at age 13 and was hospitalized at Peter Bent Brigham Hospital in Boston. Despite losing a year of school, he excelled in his studies. He was admitted to Harvard College at age 17 and subsequently to Harvard Medical School in 1928 at age 21. Rheumatic fever left him with severe aortic insufficiency and for about 10 years he had 0 diastolic blood pressure. His own onset of endocarditis, caused by Streptococcus viridans, was recognized by him in May 1931, many months before the diagnosis was accepted by his treating physicians. He faced this "incurable" disease with dignity and went on to provide a vivid and detailed chronicle of his symptoms.

The following is his description of extrasystoles, which troubled him greatly [1]:

The extrasystole has always affected me as if it were a cannon ball, shot point blank at my brain. The sensation is that of a terrific explosion, occurring within the narrow and limited confines of a calcified skull, which refuses to yield to the compressive force. It is like an irresistible force against an immovable object. Most of the time I am helpless before it and simply wait patiently in terror until the ordeal has passed.

Reinhart was convinced he had endocarditis when he noticed petechiae on his wrist [1]:

At any rate, at approximately one-quarter to twelve that night, I remember distinctly getting up from my chair and from the table, where my books lay, and taking off my suit coat. No sooner had I removed the left arm of my coat, than there was on the ventral aspect of my left wrist a sight which I never shall forget until I die. There greeted my eyes about fifteen or twenty bright red, slightly raised, hemorrhagic spots about 1 millimeter in diameter which did not fade on pressure and which stood defiant, as if they were challenging the very gods of Olympus. I had never seen such a sight before, I have never seen such a sight since, and I hope I shall never see such a sight again. I took one glance at the pretty little collection of spots and turned to my sister-in-law, who was standing nearby, and calmly said, "I shall be dead within six months."

He died of endocarditis in October 1931, after suffering complications including splenic infarcts, retroperitoneal hemorrhage, embolic stroke, sub-arachnoid hemorrhage, and pulmonary edema.

The case of Alfred Reinhart illustrates many of the protean manifestations of endocarditis, vividly described by a keen observer with medical knowledge. Despite major advances in the diagnosis and treatment of endocarditis since Reinhart's death, endocarditis remains an elusive diagnosis, and the complications which afflicted Reinhart are still observed today.

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