Infective Endocarditis: An Embolic Case

Infective endocarditis is a sudden illness that rapidly causes cardiac and extracardiac injury. Embolic material travels into the arterial circulation causing embolic events in 20-50% of patients. The brain is one of the most frequent sites of embolism that potentially interferes with treatment options. Neurologic complications are the presenting symptom in 20% of the cases being associated with poor prognosis (45% of deaths versus 24% in patients without these complications). This is the case of a 63-year-old male patient presenting with main clinic of stroke. Multifocal signs and past aortic valvuloplasty raised the suspicion of infective endocarditis and antimicrobial therapy was initiated despite an initial negative transthoracic echocardiography (TTE). Imaging study revealed vascular lesions in different arterial territories of the brain, some of them with hemorrhagic transformation and multiple splenic and renal areas of infarction. Hemodynamic instability and acute pulmonary edema developed just before surgery. Transoesophageal echocardiography (TEE) confirmed a typical image of vegetation, conditioning severe aortic regurgitation, and a perivalvar abscess with fistulization to the right ventricle. Both were surgically repaired. The immediate postoperative period was characterized by cardiogenic shock, but the patient evolved favorably being transferred to the hospital ward where he continued his motor recovery. Early surgery is a mainstay in the treatment of infective endocarditis, reducing the embolic risk. Once happened, neurologic embolization may worsen the prognosis and raise doubts about further deterioration or hemorrhagic conversion following cardiopulmonary bypass. Optimal time interval between ischemic stroke and surgery has not yet been determined but recent data favour early surgery that, when indicated, should not be delayed. Most of the embolic events occur before admission making presentation variable. Clinical suspicion is highly important to the prompt institution of antibiotic therapy and the avoidance of subsequent embolic events. TTE is a sensitive tool in the diagnosis of endocarditis, but a negative result does not exclude the diagnosis specially when endocarditis is clinicalliy expected. Imaging should be systematically performed in the course of the disease to detect new and relevant complications, always being aware of the higher sensitivity of TEE to detect intracardiac complications.