We report the case of a 61-year-old patient with a history of hypertension, who consulted for a clinical picture of a week of evolution with back and neck pain, whose intensity increased until difficulty walking.
The patient also had unquantified fever peaks, retroocular headache and constipation in stupor state 24 hours before admission to the emergency room.
On physical examination at admission, a grade II/IV systolic mitral murmur, neck stiffness and a Glasgow coma scale score of 8/15 were recorded.
Computed tomography (CT) scans were ordered, one simple brain and another contrasted, with normal results.
Due to the suspicion of meningitis, lumbar puncture was performed with cytochemical analysis of cerebrospinal fluid, which showed an increase in the number of cells, hypoglycorrhachia and hyperproteinorrhachia, as well as the presence of Gram positive cocci.
Antibiotic treatment was initiated with ceftriaxone (2 g every 12 hours), vancomycin (1 g every 12 hours) and dexamethasone (8 mg every 6 hours for 4 days).
In two hemocultives and in the cerebrospinal fluid culture, Streptococcus pneumoniae, serotype 18C was isolated at 24 hours, with a minimum inhibitory concentration (MIC) of 0.06 μg/ml vancomycin trimethoprim antibiotic and 0.05 μg
Based on these results, on the fourth day of treatment, it was decided to discontinue the administration of vancomycin and continue the management with ceftriaxone specifically directed to the isolated microorganism.
The clinical evolution of the patient remained irregular, with fever peaks during his stay in the intensive care unit, as well as leukocytosis, fallen neutrophils and constant elevation of acute phase reactants.
Control blood cultures for bacteria and right thorax were negative; however, on the eighth day of hospitalization, bilateral hypoventilation and basal rales were registered in the basal lung; alveolar infiltrates were observed in the basal lung.
Given the diagnosis of associated pneumonia and poor clinical progression, it was decided to start cefepime (2 g every 8 hours) and linezolid (600 mg every 12 hours).
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7 the presence of the cardiac mitral murmur, a transesophageal echocardiogram was obtained, which showed severe mitral regurgitation associated with rupture of the medial loop of the left atrium x posterior valve replacement 5 mm; the patient remained on the mitral valve with four mm;
The patient was admitted to the intensive care unit of level IV institution in poor general condition, was hypotensive and needed to administer vasopressors and use Swan-Ganz catheter in the first 24 hours.
He also had clinical and paraclinical signs of hypoperfusion, so he was administered inotropic, and again intensified antibiotic treatment, administering vancomycin (1 g every 12 hours) and meropenem (8 hours).
Magnetic resonance imaging (MRI) of the brain was also performed, confirming the presence of ischemic foci in several supratentorial and infratentorial vascular territories, which are considered indicative of embolism.
Gradually, partial neurological improvement was achieved, which made it possible to remove the chest tube and vasoactive drug, but the inotropic administration was maintained due to the persistence of the mitral valve with severe impairment of cardiac dysfunction.
In the Neurology Service, the patient was evaluated five days after admission and it was found that his state of consciousness was adequate, without neurological focus. Finally, on the tenth day of hospitalization, the mechanical valve was replaced #27.
The initial evolution of the patient after surgery was stable and did not require vasopressor or inotropic medication; the only complication that occurred was coagulopathy secondary to the use of extracorporeal pump, which was corrected with blood components.
In the histopathological analysis of native mitral valve biopsy acute endocarditis was reported, while Gram stain showed no bacteria and definitive cultures were negative.
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The patient remained hospitalized to optimize anticoagulation.
Ten days after surgery the patient presented clinical deterioration with hemodynamic instability and respiratory failure.
Bacterial infection due to Klebsiella pneumoniae positive for betalactamase extended spectrum (ESBL) was documented, and antibiotic treatment with meropenem and vancomycin was administered.
A new transesophageal echocardiogram showed that the mechanical prosthesis in a functioning mitral position was normal.
It was decided to perform extension studies when humoral immunodeficiency was suspected in the patient who had presented two bacteremias by encapsulated bacteria, however, immunoglobulin levels were within normal ranges.
After one week of meropenem administration, ceftriaxone was started with the intention of completing another additional week, suspending and continuing with vancomycin only until completing six weeks of endocarditis treatment.
Finally, the patient was discharged without obvious neurological sequelae and with preserved ejection fraction (60-65 %), normal left and right cavities with normal size and contractility, normal mitral mechanical prosthesis with normal function and mean gradient (6 mm Hg).
