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Infective Endocarditis with Ischemic Stroke Complication: A Case Report

Author : K.D. Krisnayanti, C.A. Shandy, G.A. Suryawati
Upload Date : 19-04-2018

Introduction: Infective Endocarditis (IE) is a rare infection of the endocardial layer of the heart caused by microorganism, characterized by vegetation formation on the infected endocardium. Clinical manifestation is vary with fatal complication, makes the diagnosis very challenging. One of its important neurological complication is ischemic stroke.

We made a summary of case report of IE with ischemic stroke complication and a review of available literature on the subject. The aim of this report is to remind us about various clinical manifestation of IE, thus requires multidiciplinary approach for diagnosis.

Result: A 36 yo man, was consulted to cardiology department due to cardiomegaly finding on his chest radiograph. He was admitted to emergency room the day before because of sudden right side body weakness and slurred speech. Brain CT revealed a generalized brain swelling. He had history of fever in the previous 2 months, improved with medication. History of chronic disease, joint pain, dental procedure and recurrent sore throat were denied. He worked as a government officer and was an active smoker. Physical examination revealed grade 3/6 blowing systolic murmur on apex radiating to axilla. Echocardiography showed severe mitral regurgitation due to two large vegetations, including 9.1x10.5 mm vegetation on AML and 8.5x12.5 mm vegetation on PML. We diagnosed patient as Possible Infective Endocarditis and started treatment with Ampicillin-Gentamycin combination. Patient was referred to Cardiac Center Sanglah General Hospital for valves repairmen and vegetations evacuation.

Discussion: Cerebrovascular involvement counts for up to 80% patient with infective endocarditis, with stroke and TIA being the most common type (40-50%). Stroke is not especially common in the young, but when they occur, it gives us some challenges for diagnostic and therapeutic method. Cardiac origin-embolism always need to be taken into consideration, after other more frequent caused has been ruled out. The patient presented with neurological manifestation as the main complaint, with fever history and abnormal physical examination finally directed him toward further investigation for the cardiac risk factor. The finding of vegetation from the echocardiography completed the Modified Duke Criteria and this patient was then diagnosed as Possible Infective Endocarditis. Immediate initiation of appropriate antibiotic decreases risk of systemic embolization to the brain. The decision on surgical timing in IE with neurological complication requires a balance between the urgency of the operation for cardiac indications versus the perceived risk of exacerbation of neurological injury. This patient had higher risk of embolic event, because of large vegetation and mitral valve involvement, so early surgery was recommended.

Conclusion: Ischemic stroke is the most common neurological complication of IE as the consequence of embolism from vegetation. Rapid diagnosis using Modified Duke Criteria and initiation of appropriate antibiotics are mandatory for the treatment and complication prevention. Early surgery is indicated in high risk patients for embolic prevention.

KEYWORDS : infective endocarditis, ischemic stroke, vegetation, emboli.

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