Gul Madison, MD Mercy Catholic Medical Center DARBY, Pennsylvania, United States
Introduction: The incidence of Infective Endocarditis (IE) has been on the rise with approximately 3-7.5 cases/ 100,000 persons per year. Despite recent advancements, IE is still associated with high mortality and morbidity. Bacterial meningitis as the presenting symptom of IE has been noted, however here we discuss an extremely unusual case of IE with Aseptic Meningitis (AM) as the first manifestation.
Description: A 33-yoF with no past history presented to the ED with worsening mental status, headache, and fevers for 3 days. She denied smoking, drug use, alcohol use, and history of recent dental work. Vitals on arrival - rectal temperature 106F, BP of 94/51mmHg, HR 124bpm. On physical exam, she was lethargic. Neck was supple, Kernig’s and Brudzinski’s signs were negative. Bilateral subconjunctival hemorrhages, 1-2 mm petechiae on the face, chest, and lower extremities were seen. CXR, CT, MRI brain were unremarkable. Labs showed WBC of 16.3 cells/mm3, lactate 3.3. Prompt LP was performed. Empiric antimicrobials were initiated. CSF analysis showed WBC of 31 cells, protein of 57mg/dL (15-40mg/dL), glucose 77mg/dL( 40-70mg/dL), with neutrophilic predominance. Meningitis-Encephalitis viral panel was negative. A working diagnosis of AM was made. 4/4 bottles of initial blood cultures isolated Methicillin Sensitive Staphylococcus Aureus (MSSA). Antibiotics were narrowed to IV Nafcillin. TTE showed normal valves, EF of 42%, and peak troponin 2.53. On day 3, she reported painful nodules on her fingertips. Splinter hemorrhages were also noted. TEE confirmed a 0.8 x 0.8cm echodensity on the aortic valve. After clinical improvement, she was discharged with 6 weeks of IV cefazolin. Complete recovery with no residual deficits was noted during her follow-up.
Discussion: IE can be complicated by both occult and overt neurologic disease, with meningitis occurring in 3.5% of the cases. Most neurological sequelae in IE are due to embolization to the CNS causing meningeal irritation and CSF pleocytosis. Our case was rather bizarre, presenting as AM. Thus cases of MSSA bacteremia and AM should be aggressively evaluated for underlying IE through a thorough history of valvular disease, dental manipulation, and fevers. Burdened by high mortality-morbidity rates of IE, prompt management is vital to prevent fatal outcomes.
