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 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 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 PMH: PSH: Anterior cervical discectomy and fusion of C5-C6 for spinal stenosis 5 weeks ago Carpal tunnel release 6 years ago Meds: Diabetes x 20 years Hypertension x 10 years Low back pain x 30 years Glipizide 5 mg QD Lotensin 10 mg QD Allergies: NKDA History Continued SH: FH: 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: Otherwise negative Physical Vitals: RRR, Grade III/VI diastolic murmur at LSB 5th intercostal space with radiation to the left axilla Clear, with good tidal volume Abd: Supple, normal ROM, no JVD, no bruits, mature surgical scar left anterior triangle Lungs: ATNC, PERRLA, EOMI, no nystagmus, no lymphadenopathy, Heart: Well developed, slightly emaciated, no acute distress, dysarthic speech Neck: Pulse Ox: 99% HEENT: BP: 138/80 RR: 20 General: Temp: 99.9 Tmax: 103.0 HR: 89 Soft, NT, ND, positive bowel sounds, normal rectal tone, guiac negative Ext: pulses +2, no edema Physical Continued Back: Tenderness to palpation in the low back Neuro: A&O x4 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 • • • • PT: 13.3 PTT: 29.4 INR: 1.2 UA: no white cells, leukocyte esterase and nitrate negative • ESR: 57 EKG Imaging Chest X-Ray: Read as normal Noncontrast Head CT: (image lost) 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 Infective endocarditis: Infection of the endocardial surface of the heart cardinal lesion is the vegetation bacteremia, adherence, invasion and growth ineffective immunological response poor vascular supply decreased complement ability fibrin deposition usually occurs in high risk conditions nonbacterial thrombotic endocarditis (NBTE) vasculitis, renal failure, neoplasm prosthetic heart valve, Hx of endocarditis, congenital lesions, rheumatic heart disease, mitral valve prolapse, hypertrophic cardiomyopathy Disease Process Acute Different etiological causes due to predisposing factors IVDA: most commonly Staph. aureus. Acute Prosthetic Valve: Staph. aureus. 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 Subacute Predisposing factor Mitral most common Aortic Mitral and Aortic Tricuspid Rarely involves pulmonary valve Streptococcus species Most common Strep. viridians, Coagulase Negative Strep, Enterococcus Origin: dental, skin, GI, GU HACEK Immunological / vasculitic phenomena usually present More likely to have a murmur detectable Systemic embolization Disease Process Special Cases Fungal endocarditis Candida and Aspergillus Consider in immunocompromised or immunosuppressed HIV, IVDA, chemotherapy Bartonella species Homeless males with terrible hygiene Disease Process Complications Valvular insufficiency Embolic phenomena CHF Sterile Septic Death Relevance Rare disease Incidence of 2-4 per 100,000 Underlying etiology has changed rheumatic heart disease has decreased prosthetic valves has increased aortic stenosis “Can’t miss” diagnosis Untreated IE: Fatal Treated native valve IE: approximately 20% Treated prosthetic valve IE: 20-60% ED Encounter Fever and local neuro findings Non-anatomical lesion: 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: Focal high diffusion weighted signal lesions suggestive of acute infarctions: 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 Classic triad for infective endocarditis: Common findings: fever (intermittent) anemia heart murmur weakness headache chest pain (pleuritic) shortness of breath anorexia Absence of vasculitic findings: 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 Acute versus Subacute Acute No vasculitic changes noted Acute more likely to embolize History of recent surgery Subacute 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 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 Meeting Duke’s criteria: Two Major 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 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.