Clinical & Experimental Cardiology
Open Access
ISSN: 2155-9880
+44 1300 500008
ISSN: 2155-9880
+44 1300 500008
V P Rambhujun
NYU Winthrop Hospital, USA
Posters & Accepted Abstracts: J Clin Exp Cardiolog
Introduction: DKA is characterized by hyperglycemia, acidemia, bicarbonate, anion gap and ketonemia, and its occurrence is 14% of diabetics for patients greater than 70 years of age. Infection remains a common cause for DKA, though its association with endocarditis is rare. The incidence of infective endocarditis (IE) ranges from between 1.5 to 11.6 per 100 000, prosthetic valve endocarditis occurs in 1-6% of patients and rarely it is bilateral, same as in this case. Case Presentation: The case study begins with a 71-year-old female with history of type-2 diabetes and hypertension presented to our ED for progressive weakness. ROS was positive for polydipsia, polyuria and daily fevers. Initial examination found her to be hypotensive, tachycardia and afebrile. Her laboratory analysis showed evidence for DKA, with blood sugars above 600, pH of 7.00, high anion gap, ketonemia and bicarbonate 8 mEq/L, creatinine of 4.8 mg/dL and a leukocytosis of 14 K/uL. The patient was admitted to the medical ICU for management of DKA and hypovolemic shock. She was initiated on intravenous hydration and norepinephrine. As infection is often an etiology of DKA, blood cultures were drawn that grew Streptococcus mitis two days later. This organism has a known association with infective endocarditis and transthoracic cardiac echocardiogram was performed, which was unremarkable. However, given the high degree of suspicion, a transesophageal cardiac echocardiogram was ordered, and it revealed the presence of vegetation over the tricuspid and bioprosthetic aortic valve, thus establishing a diagnosis of bilateral endocarditis. Following this, the cardiothoracic surgical team was consulted, and the decision was made to not surgically intervene as her condition was improving swiftly with intravenous antimicrobial agents. Prior to discharge, a repeat TEE showed reduction in size of the vegetations. She was subsequently discharged after two weeks to complete a six week course of ceftriaxone. Discussion: The unique feature of our case was the presence of bilateral vegetations. Our literature review revealed only one such case; where there was involvement of the tricuspid and aortic valves in the presence of a VSD. Streptococcus mitis is commonly implicated in bacterial endocarditis and is part of the oral flora. Our patient was bacteremic from this organism without recent dental work. Streptococcus mitis often causes more aggressive endocarditis, which in our patient�??s case were bilateral vegetations. A negative TTE should not exclude the diagnosis of IE in high risk cases as sensitivity of this test is 50 to 60% hence our resort was to perform TEE. Current guidelines do not address bilateral endocarditis. Our case lends support that following established medical practices for IE and DKA can be successful for treatment in patients with bilateral endocarditis.