SAEM Boston 2003 CPC Presentation
Jeff Hurley MD
Emergency Medicine
Martin Luther King Hospital
Charles Drew University
History
CC: Left sided weakness, facial droop, and difficulty
speaking X 4 hours
HPI: 53 yo Hispanic male with PMH of diabetes
mellitus type II, hypertension, and “heart trouble”
was brought in by paramedics with a complaint of
weakness on the left side of his body including
difficulty controlling his mouth and difficulty
speaking over the last 4 hours.
History Continued
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Patient states that he was in a jacuzzi when all of a sudden he
started feeling weak and dizzy. When he attempted to walk, he
noted that he had decreased strength and coordination. He also
noted that he that he had some difficulty speaking clearly and
was drooling. In addition, the patient complained of a low
severity non-radiating dull chest pain worse with inspiration,
some shortness of breath, and a headache since being in the
jacuzzi. The patient went home and decided to take some
Tylenol, and when that didn’t resolve his symptoms, he
became concerned and called EMS.
History Continued
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In the previous ten days he states that he has
had fever and chills, and over the last two
months, greater than 20 pounds of weight loss.
He also states that he has had increasing back
pain over the last two weeks. The patient
denied the presence of any diplopia, seizure
disorder, nausea, vomiting, diaphoresis, or
palpitations.
History Continued
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PMH:
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PSH:
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Anterior cervical discectomy and fusion of C5-C6 for spinal stenosis 5 weeks
ago
Carpal tunnel release 6 years ago
Meds:
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Diabetes x 20 years
Hypertension x 10 years
Low back pain x 30 years
Glipizide 5 mg QD
Lotensin 10 mg QD
Allergies:
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NKDA
History Continued
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SH:
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FH:
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Smokes ½ to 1 pack per day for 35-40 years
Few beers a day for 20 years
Denies illicit drug use
Diabetes: Parents and siblings
ROS:
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Otherwise negative
Physical
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Vitals:
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RRR, Grade III/VI diastolic murmur at LSB 5th intercostal space with radiation to the
left axilla
Clear, with good tidal volume
Abd:
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Supple, normal ROM, no JVD, no bruits, mature surgical scar left anterior triangle
Lungs:
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ATNC, PERRLA, EOMI, no nystagmus, no lymphadenopathy,
Heart:
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Well developed, slightly emaciated, no acute distress, dysarthic speech
Neck:
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Pulse Ox: 99%
HEENT:
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BP: 138/80 RR: 20
General:
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Temp: 99.9 Tmax: 103.0 HR: 89
Soft, NT, ND, positive bowel sounds, normal rectal tone, guiac negative
Ext:
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pulses +2, no edema
Physical Continued
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Back:
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Tenderness to palpation in the low back
Neuro: A&O x4
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Cranial Nerves: Visual fields intact, EOMI, slightly decreased pinprick on left
side of face, otherwise sensory intact, facial droop on the left with the frontalis
muscle preserved, hearing intact, good gag reflex, SCM and trapezius normal
strength, hypoglossal intact
Motor: 4/5 strength left upper extremity and left lower extremity, 5/5 strength
on the right
Sensory: slightly decreased pinprick sensation on left upper and lower
extremity
Cerebellar: Finger to Nose: decreased with left arm, Heel to Shin: bilateral
disorganization of movement (possibly secondary to back pain)
Gait: antalgic, slight limp, otherwise narrow
Laboratory
• Differential:
– 64.5% PMNs, 22.5% Lymphs, 10.0% Monos, 1.3% Eosinophils
•
•
•
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PT: 13.3
PTT: 29.4
INR: 1.2
UA: no white cells, leukocyte esterase and nitrate
negative
• ESR: 57
EKG
Imaging
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Chest X-Ray: Read as normal
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Noncontrast Head CT: (image lost)
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Triangular sharp low attenuation area,
approximately 2 cm, with edema/hemorrhage
located right parietal lobe superiorly
End
Diagnosis
1: Multiple acute cerebral vascular
accidents secondary to septic emboli
from infective endocarditis
2: Discitis
3: Paraspinal Abscess
Septic Embolism
Septic Embolism
Disease Process
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Infective endocarditis: Infection of the endocardial
surface of the heart
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cardinal lesion is the vegetation
bacteremia, adherence, invasion and growth
ineffective immunological response
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poor vascular supply
decreased complement ability
fibrin deposition
usually occurs in high risk conditions
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nonbacterial thrombotic endocarditis (NBTE)
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vasculitis, renal failure, neoplasm
prosthetic heart valve, Hx of endocarditis, congenital lesions,
rheumatic heart disease, mitral valve prolapse, hypertrophic
cardiomyopathy
Disease Process
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Acute
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Different etiological causes due to predisposing factors
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IVDA: most commonly Staph. aureus. Acute
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Prosthetic Valve: Staph. aureus.
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Talc
Normal valves / Right-Sided
HACEK (Haemophilus aphrophilus, Actinobacillus, Cardiobacterium hominis, Eikenella
corrodens, Kingella kingae)
 usually subacute
 large-vessel septic emboli
P. aeroginosa
More likely with mechanical
Fever likely
Murmur maybe difficult to detect
May infect previously normal valves
Less likely to have vasculitic lesions
Right sided emboli to lungs
Disease Process
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Subacute
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Predisposing factor
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Mitral most common
Aortic
Mitral and Aortic
Tricuspid
Rarely involves pulmonary valve
Streptococcus species
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Most common Strep. viridians, Coagulase Negative Strep, Enterococcus
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Origin: dental, skin, GI, GU
HACEK
Immunological / vasculitic phenomena usually present
More likely to have a murmur detectable
Systemic embolization
Disease Process
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Special Cases
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Fungal endocarditis
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Candida and Aspergillus
Consider in immunocompromised or
immunosuppressed
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HIV, IVDA, chemotherapy
Bartonella species
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Homeless males with terrible hygiene
Disease Process
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Complications
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Valvular insufficiency
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Embolic phenomena
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CHF
Sterile
Septic
Death
Relevance
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Rare disease
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Incidence of 2-4 per 100,000
Underlying etiology has changed
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rheumatic heart disease has decreased
prosthetic valves has increased
aortic stenosis
“Can’t miss” diagnosis
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Untreated IE: Fatal
Treated native valve IE: approximately 20%
Treated prosthetic valve IE: 20-60%
ED Encounter
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Fever and local neuro findings
Non-anatomical lesion:
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Ipsilateral findings of left facial droop and left sided weakness suggest
cortex involvement prior to decussation
However not consistent with the motor homonucleus based on size of
the lesion and location
Suggested multiple lesions
MRI Reading:
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Focal high diffusion weighted signal lesions suggestive of acute
infarctions:
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right basal ganglion, right frontal lobe, and right parietal lobe
Focal hemorrhagic acute infarction was prominent in the right parietal
lobe with ring enhancement suggestive of an infectious etiology
Parietal Lesion / Basal Ganglia
Frontal Lesion
ED Encounter
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Classic triad for infective endocarditis:
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Common findings:
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fever (intermittent)
anemia
heart murmur
weakness
headache
chest pain (pleuritic)
shortness of breath
anorexia
Absence of vasculitic findings:
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no Roth spots, Osler nodes, Janeway lesions, splinter hemorrhages
suggested an acute as opposed to a subacute etiology
concern of a post-operative infection
Transthoracic Echocardiogram TTE:
Longitudinal
Apex View
Transthoracic Echocardiogram
 Demonstrated thickening of the mitral valve leaflet
with vegetation
ED Encounter
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Acute versus Subacute
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Acute
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No vasculitic changes noted
Acute more likely to embolize
History of recent surgery
Subacute
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History of heart trouble
EKG: left atrial enlargement, left ventricular
hypertrophy
Left-sided murmur
EKG: PVCs, LVH, LAE
MRI Cervical Spine
MRI Lumbar Spine: Discitis
Discitis
Paraspinal Abscess
Outcome
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Patient improved greatly during hospital stay
Started on vancomycin, gentamycin, and ceftriaxone in the
emergency department
Blood cultures positive on day #2 for Strep. Viridians
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Meeting Duke’s criteria: Two Major
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Major: blood cultures, endocardial vegetation (did not meet new
regurgitation criterion)
Minor: fever, arterial emboli
Repeat blood cultures were negative in two days
Patient transferred to rehabilitation center for IV Abx.
Unfortunately within the last two months, the patient returned
to the ED with acute onset of painless monocular loss of vision
and was diagnosed with central retinal artery occlusion.
Resolution of Facial Droop
References
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Marx JA et al. Rosen’s Emergency Medicine
Concepts and Clinical Practice 5th ed. Mosby.
St. Louis 2002.
Pelletier, L Jr. Infective Endocarditis.
www.emedicine.com May 16, 2003.