A 20-year-old male presented to the emergency department with fever of 39oC for 4 days with chills, moderate dyspnea, nausea and vomiting accompanied by diffuse abdominal pain.
The patient had been healthy without previous diseases of interest.
He had no contact with animals, nor had he consumed dairy products without animals.
He had not suffered any dental manipulation or other recent instrumentation.
Examination at admission was: blood pressure 90/50 mmHg, temperature was 38.5oC.
He was alert, oriented, with good general condition, well perfused, and normal color.
He had mild tachypnea.
There was no jugular venous engorgement and the carotid arteries were symmetrical.
Upon auscultation, the heart beat rhythmic, with a prostatic murmur II-III/VI in aortic focus.
The vesicular murmur was preserved.
Abdominal palpation revealed diffuse pain without peritoneal mass or organomegaly.
The intestinal peristalsis was conserved.
There were no signs of neurological involvement or focality.
Peripheral pulses were present.
No petechial lesions or other dermal lesions were observed.
Laboratory tests showed leukocytosis of 13.900/mm3 with left shift and marked thrombopenia of 54.600/mm3.
The red series and plasma coagulation tests were normal.
Peripheral blood smear showed leukocytosis with marked leukocyte granulation.
Urea was 39 mg/dl and creatinine 1.4 mg/dl. Electrolytes were normal.
The chest X-ray was normal.
Hemocultives were obtained and empirical antibiotic treatment with levofloxacin was initiated, entering the plant.
In the following hours, the patient presented sudden deterioration with intense tachypnea, signs of peripheral hypoperfusion, fine crackles scattered at auscultation with cardiac tones tachyarrhythmics without response to arterial hypotension.
Located to the Intensive Care Unit.
An urgent chest X-ray showed signs of cardiac failure.
The patient suffered cardiorespiratory arrest.
Despite advanced cardiopulmonary resuscitation maneuvers with orotracheal intubation and connection to mechanical ventilation, fluid and vasoactive drugs, the patient died.
In the post-mortem examination, the most relevant macroscopic findings were: in the craneal cavity, loss of transparency of the meninges, extensive ventricular septal rupture with pericardial cavity and extensive necrosis of the left ventricle with pericardial cavity;
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Microscopically, the extensive ischemic heart valve involved extensive coronary abscesses in its valves fibrin accumulation in the form of vegetations, with multiple images of microorganisms within it; an intense polymorphonuclear infiltrate was observed from endocardium to pericardium.
Subsequently, HIV serology was negative.
Both in the previous blood culture and postmortem culture of pericardial fluid, streptococcus pneumoniae serotype 18C grew, sensitive to penicillin.
Pleural and ascitic fluid cultures were negative.
