Although negative for PE, his CT had concerning findings including an ascending thoracic aortic aneurysm measuring 4.1 cm, as well as ground-glass densities of the lungs. After a discussion with the patient and his mother, a computed tomography (CT) with contrast to rule out pulmonary embolism (PE) was ordered. The decision was made to draw a D-dimer, which came back elevated at 721 μg/L. His electrocardiogram was otherwise normal. The patient was given a 1 L bolus of normal saline, but remained tachycardic on re-examination with a heart rate as high as 134 bpm. Basic labs including a blood count and basic metabolic panel were drawn that were significant only for an unexplained anemia with a hemoglobin of 8.9 g/dL. A radiograph of the right foot was negative for fractures or dislocations.
ERICA ESCARCEGA SKIN
The classic skin findings of endocarditis, including Janeway lesions, Osler nodes and splinter hemorrhages, were not present. Distal perfusion and sensation of the foot were intact.
On examination of the right foot and ankle, he had tenderness over the dorsum of the foot and pain with range of motion of the ankle. He had normal breath sounds, was not tachypneic, and had a normal oxygen saturation. On initial examination, the patient was well appearing, but tachycardic at 118 beats per minute (bpm) with a grade 2/6 systolic murmur. He denied intravenous drug use or recent dental procedures. The patient had been afebrile for the prior week, but he had continued to have problems with fatigue and night sweats and had recently developed exertional dyspnea. He had completed one 10-day course 2–3 weeks prior to his presentation with only minimal improvement in his symptoms and had been started on a second 10-day course. Patient had also been having symptoms of fatigue, night sweats and fever for which his primary care physician had prescribed levofloxacin. He had been treated for plantar fasciitis in both feet by his podiatrist and had received a cortisone shot in the left foot three weeks earlier. He denied any recent strenuous activity or injury to the foot, but had been dancing at his prom the previous night. He had taken ibuprofen at home with no improvement in his symptoms. The patient indicated that the pain was primarily over the dorsal aspect of the foot, radiated up the back of the calf and was worse with bearing weight and movement. He had awoken at 4:30 am that morning and found that he could no longer bear weight on the right foot due to the intensity of the pain and had been using an old set of crutches to ambulate around his home. CASE REPORTĪn 18-year-old male with history of bicuspid aortic valve presented to the emergency department (ED) the day after his senior prom with the chief complaint of right foot pain that had been gradually worsening over the prior three days. 2, 3 Here we describe a case of subacute bacterial endocarditis in a previously healthy young male with history of bicuspid aortic valve. 2, 3, 4 Unfortunately, this bacteria is often pleomorphic on Gram stain and is difficult to isolate, requiring specialized media and, therefore, may be the cause of some cases of culture-negative endocarditis. 1, 2 This little-known bacteria is part of the normal oral flora making dental procedures a commonly implicated source of infection. INTRODUCTIONĪbiotrophia defectiva, once classified as a nutritionally variant strain of streptococci, is a rare but important cause of infective endocarditis with potentially devastating consequences due to its high rates of embolization, bacteriological failure and mortality.
This report discusses the case of an 18-year-old male discovered to have severe endocarditis after presenting to the emergency department with the chief complaint of foot pain. A potentially lethal form generated by infection with Abiotrophia defectiva may be easily overlooked early in its presentation. Subacute endocarditis often presents with an indolent course.
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