Cards: AV Endocarditis presenting as back pain

DON’T FORGET TO
SWIPE!!!

Morning Report
April 10th, 2012
Roderick Deaño
Jack Ende, MD
Parker Ward, MD

MKSAP
A 51-year-old woman is evaluated during a routine
physical examination. She has no history of hypertension
and has never used tobacco. There is no family history
of heart disease. Her only medication is daily oral
conjugated estrogens combined with
medroxyprogesterone acetate for intolerable hot flushes.
Physical examination is normal. BMI is 31. A fasting lipid
panel is obtained with the following results: total
cholesterol, 218 mg/dL (5.65 mmol/L); HDL cholesterol,
42 mg/dL (1.09 mmol/L); LDL cholesterol, 128 mg/dL
(3.32 mmol/L); triglycerides, 240 mg/dL (2.71 mmol/L).

Which of the following is the most
appropriate next step in the
management of this patient?
A. Calculate
Framingham risk score
B. Calculate non-HDL
cholesterol level
C. Prescribe
atorvastatin
D. Prescribe
gemfibrozil
0% 0% 0% 0%
1 2 3 4

The most appropriate management option for this patient is to calculate her non-HDL cholesterol
level. This patient has a high triglyceride level (>200 mg/dL [2.26 mmol/L]). According to the Adult
Treatment Panel III guidelines, the next step in the management of a patient with a triglyceride
level between 200 mg/dL and 500 mg/dL (2.26 and 5.65 mmol/L) is to calculate non-HDL
cholesterol (total cholesterol minus HDL cholesterol) to determine whether triglyceride-lowering
medication is indicated. In addition, reversible causes of hypertriglyceridemia should be sought.
These include excessive alcohol intake, obesity, high carbohydrate intake, physical inactivity, type
2 diabetes mellitus, renal disease, and certain medications (corticosteroids, β-blockers, estrogens,
and protease inhibitors).
LDL cholesterol goal is based on the presence or absence of five major risk factors (smoking,
hypertension, older age, low HDL cholesterol, family history of premature coronary artery
disease). This patient does not have any of these risk factors; therefore, her LDL cholesterol goal
is 160 mg/dL (4.14 mmol/L), and she does not need a statin.
The second therapeutic target is the non-HDL cholesterol. The non-HDL cholesterol goal is set at
the LDL goal plus 30 mg/dL (0.78 mmol/L); therefore, her non-HDL cholesterol goal is 190 mg/dL
(4.92 mmol/L). This patient’s non-HDL cholesterol level is 176 mg/dL (4.56 mmol/L); therefore,
triglyceride-lowering medication (gemfibrozil or other fibrate medication) is not indicated.
Triglyceride-lowering medication should be considered in patients with a personal or family history
of premature coronary artery disease regardless of non-HDL cholesterol level. The patient
presented has no family history of premature coronary artery disease.
The Framingham risk score, used to further stratify some patients with elevated LDL cholesterol,
does not have to be calculated in this patient because her LDL cholesterol of 128 mg/dL (3.32
mmol/L) is below the goal of 160 mg/dL (4.14 mmol/L). Calculating the Framingham risk score is
most helpful in making management decisions when patients have an LDL cholesterol level above
their target goal.

61yom presents to your PCP
clinic:
“Doc, I have this pain in my
lower back.”

Lower Back Pain – Persistent, non-radiating;
happening for two months, non-exertional, no
trauma to area, no distal paresthesias,
incontinence or lower extremity weakness. Not
relieved with lying down or OTC NSAIDS. No
F/C, no weight loss
L UE Weakness – starting 3 days ago while
changing his clothes, w no parasthesias or
decrease sensation
Went to OSH ED, CT Head was negative
Presents bc LUE weakness still persists

PMH:
ESRD x 10 yrs – MWF HD;
secondary to HTN
R Femoral Tunneled
catheter
HTN
PE – diagnosed OSH 9
months ago on coumadin
(unclear if had
hypercoagulable w/u)
? CVA (per history) approx
20 yrs ago w resolved R
sided weakness
OSA on CPAP
H&P
NKDA
MEDS: Albuterol prn; Renvela
TID; Nifedipine 60 mg qday;
diazepam 5mg qhs; vit D;
coumadin
Social Hx: former security
guard; separated w 5 healthy
children; former crack use
(smoked); last use 2 yrs ago;
no IVDU; never smoker; quit
ETOH, used to drink 1 pint
every other week w three
friends
FH: non-contributory

Differential?

focused history and physical examination to help place patients with
low back pain into 1 of 3 broad categories:
nonspecific low back pain,
back pain potentially associated with radiculopathy or spinal
stenosis,
or back pain potentially associated with another specific spinal
cause.
no routine imaging or other diagnostic tests in patients with
nonspecific low back pain
diagnostic imaging for low back pain when severe or progressive
neurologic deficits are present or when serious underlying conditions
are suspected
evaluate patients with persistent low back pain and signs or
symptoms of radiculopathy or spinal stenosis with MRI or CT only if
candidates for surgery or epidural

Physical Exam
VS: AF (36), HR 89 BP 101/40 RR 20 94% on 2L
GEN: AAM, looks appropriate age, no acute distress
HEENT: NC/AT EOMI PERRL, Anicteric clear O/P; no
supraclavicular/axillary LAD, no thyromegaly
Chest: CTAB, No W/R
CV: RRR, Nl S1, S2, Diastolic murmur; JVP 12cm above RA, 2+
radial/dp pulses, warm extremities w good cap refill. Nl carotid upstroke
Abd: soft obese, NTND, +BS
Ext: No LE Edema; warm extremities; erythema around the R femoral
catheter
Neuro: CNII-XII intact, A&O x3; no focal deficits; normal sensation; no T
in the cervical/thoracic/lumbar spine
Musk: 5/5 Strength LE BL; 4/5 LUE; 5/5 RUE;
Skin: no rashes; no track marks in UE’s.

What initial diagnostics
to you want to order?

CT Head
Small focus of SAH isolated in R central
sulcus w/o evidence of parenchymal
edema
Minimal small vessel disease of
indeterminate age
Pt admitted for SAH, in setting of
therapeutic INR

5.1
11.3
Lab Tests
156
N 78; no bands
7.7 3.5
0.3 0.2/0.2
15 7
128
138 93 23
4.0 30 6.7 84
INR 2.4
BC’s Pending
HIV pending
UA neg
Utox neg
8.9
2.1
4.3

Chest Xray

TTE

TTE
LV: nl size; mild LVH; nl EJF (60-65%); No
WMA
RV: moderately dilated; moderately
reduced
LA: mildly dilated and dilated IVC: nl RA
Trace MR; trace TR; moderate AR
Estimated RV: 53.5 + RA

Course Continues
Admitted to Neuro ICU for SAH
FFP Given to reverse INR
L Femoral quinton exchanged over a wire for another HD
Catheter, cultures sent
BC from first day positive 2/2 for CONS (2 bottles) and
Staph Hominus (1/2); HIV neg
Pt has increased O2 requirement and now requiring
intermittent BiPap for increased WOB
ABG 7.35/44/85/95% (on NRB 100%)
Pt started on empiric Vanc/Cefepime
CRP 124

Next Management Steps?

MRI Lumbar/Thoracic
Abnl increased signal intensity of
intervertebral disk spaces @ T8-9 w
associated adjacent marrow signal abnl of
vertebral bodies raising concern for
discitis/osteo; increased signal intensity of
intervertebral disc @ T7-T8

MRI Head
Focus of restricted diffusion on R
precentral gyrus of frontal lobe associated
w parenchymal and subarachnoid
hemorrhage; vasogenic edema
surrounding this region raises possibility of
infected embolic stroke.

TEE

LV: nl performance
TEE
Atria: no mass or thrombus
Mild MR w moderate mitral annular
calcification
Trace TR
Moderate-sized vegetation/mass on AV 1
1.2 cm pedunculated mass on aortic
leaflet c/w vegetation; severe AR

ECG

ECG
Mobitz Type II AV Block and Sinus
Bradycardia
*Pt was actually in Normal Sinus

Clinical Summary
Pt has likely mycotic aneurysm causing
SAH, Endocarditis with Acute AR; discitis
and osteomyelitis
Pt is SOB with increasing oxygen
requirement
Now transferred to medicine service
(CCU) for better coordination of medical
care
Next Management steps?

10-40% of patients with left sided endocarditis have
neurologic complications
Embolic CVA, ruptured mycotic aneurysm, TIA, meningitis, brain
abscess, seizure
Safety of cardiopulmonary bypass w acute neurologic
deficits (such as hemorrhage) and active endocarditis
Reviewed charts and found 247 patients that underwent
repair of valve for endocarditis
34 had pre-operative neurologic deficits
More neurologic deficits in pts who underwent surgery
within 11 days of acute neurologic event
Many of those patients were hemodynamically unstable and
needed to go urgently

Clinical Management
How would you manage the patient in the
meantime: acute AR and endocarditis?
What are some of the important things to
watch for re: endocarditis?

Acute AR
Circulation 2009, 119:3232-3241

Acute AR
Chronic regurgitation of AV affords time for the ventricle
to dilate to accommodate the regurgitant volume to
maintain forward SV and CO
LV does not compensate; initial compensatory
tachycardia may preserve cardiac output initially, but
eventually hypotension, organ failure, and other
evidence of cardiogenic shock will develop.
Pulmonary capillary wedge pressure increases abruptly and
pulmonary edema develops
Present with dyspnea, hemodynamic instability, and
symptoms of shock, including weakness, dizziness, and
AMS
Circulation 2009, 119:3232-3241

Acute AR - Treatment
Surgical Emergency
Medically Stabilize until surgery
Decrease LVEDP
Consider afterload reduction if BP can tolerate
to improve forward flow
Consider inotropic support to augment CO
Griffin, Topol, 2009; Circulation 2009, 119:3232-3241

Endocarditis – Duke Criteria
Circulation 2005, 111:e394-e434

Endocarditis - Complications
CHF
Embolization
Higher rates with left sided vegetations; greater than 1cm in size
Peri-annular extension of infection
Occurs in the weakest portion of the annulus in native valve IE,
near the membranous septum and AV Node
Daily EKG for monitoring
Splenic abscess
Mycotic aneurysms
septic embolization of vegetations to the arterial vasa vasorum
or the intraluminal space, with subsequent spread of infection
through the intima and outward through the vessel wall.
Circulation 2005, 111:e394-e434

Hospital Course
SCUF/CVVH for more fluid off
Started vasodilators for afterload as BP
tolerated
Cath – non-obstructive Disease
Repeat CTA head– no evidence of any
aneurysm

Surgical Repair

Further Hospital Course
Successful surgery with replacement with
Tissue Aortic Valve
Subsequent CTA Head negative for
aneurysm
CT PE positive for multiple segmental PE
– started on heparin (and eventually
coumadin) after cleared by Neuro
Discharged on IV Vanc for 8 weeks to
rehab

Take Home Points
Low Back Pain workup
Management of Acute AR
Complications of Endocarditis

Thank you!

References
1. Baddour, Wilson, et al. “Infective Endocarditis.” Circulation 2005,
111:e394-e434
2. Chou, R.; Qasem, Amir.; Vincenza, S, et al. “Diagnosis and Treatment of
Low Back Pain: A Joint Clinical Practice Guideline from the American
College of Physicians and the American Pain Society“. Ann Intern Med.
2007;147:478-491
3. Enriquez-Sarano M, Tajik AJ. “Clinical practice. Aortic regurgitation.” N
Engl J Med. 2004 Oct 7;351(15):1539-46
4. Gillinov AM, Shah RV, Curtis WE, Stuart RS, Cameron DE, Baumgartner
WA, Greene PS. “Valve replacement in patients with endocarditis and
acute neurologic deficit.” Ann Thorac Surg. 1996 Apr;61(4):1125-9
5. Griffin, Topol, et al. Manual of Cardiovascular Medicine. Third Edition.
Wolters Kluwer. 2009
6. Stout KK, Verrier ED. “Acute valvular regurgitation. Circulation. 2009 Jun
30;119(25):3232-41. Review.
7. UTD – “Low back pain.”

ADDENDUM

AR Table

DON’T FORGET TO
SWIPE!!!