A 68-year-old female was presented with 10 days history of fever. The fever was mild to moderate in severity and associated with chills but no rigors. She also had exertional dyspnoea (NYHA class III), orthopnoea, and paroxysmal nocturnal dyspnoea. Simultaneously, she complained of dysuria, haematuria, frequency, and urgency at the onset of fever which was persistent throughout the illness, and intermittent episodes of constipation, passing stool once in four days for the preceding few weeks. She also had bilateral lower limb swelling up to mid-calf level, and the onset of the heart failure symptoms was about 4 days after the onset of fever. She did not have any history of chest pain, cough, pleurisy, headache, abdominal pain, diarrhea, or vomiting. She did not have any history of per rectal bleeding or alteration of bowel habits. Her daily water intake was low mainly due to poor personal care, which may have been the main cause of constipation. She was not allergic to any drugs, foods, or plasters, and her family history did not reveal any heart diseases or malignancies.
She was a known patient with bilateral knee joint osteoarthritis where she was on long-term non-steroidal anti-inflammatory drugs and proton pump inhibitors, and she did not complain of any knee joint pain in the current admission. She had undergone a total abdominal hysterectomy with bilateral salphingo-oophorectomy at 51 years.
On examination, she was obese (body mass index of 31.2 kg/m2), febrile 100 ˚F, the vital parameters recorded, blood pressure of 150/90 mmHg, pulse rate of 96 beats per minute. She did not have any peripheral stigmata of infective endocarditis. However, she had tender hepatomegaly on abdominal examination with liver palpable 3 cm below the right subcostal margin. The remaining cardiovascular, respiratory and neurological system examination was unremarkable.
The initial investigations on admission revealed a white cell count of 24.99 × 103 /µL (neutrophils 86.9%), a hemoglobin level of 12.1 g/dL, platelet count of 154 × 103 /µL. The inflammatory markers were elevated, c-reactive protein of 148.4 mg/L, and erythrocyte sedimentation rate of 100 mm/1st hour. The blood picture was suggestive of the evidence of severe sepsis, and the urinalysis revealed a moderate field full of pus cells per high power field and 12–15 red cells per high power field, with dysmorphic red cells being visible. Her urine culture became positive for Escherichia coli (> 105 CFU), and her blood culture also isolated Escherichia coli organisms in two out of three separate cultures, the first and last one taken more than one hour apart.
Since the patient had clinical features of heart failure, a 2D echocardiogram was performed, which revealed an oscillating mass attached to the posterior valve leaflet of the mitral valve, vegetation concluding the diagnosis of infective endocarditis secondary to bacteremia following a urinary tract infection by Escherichia coli. However, the cardiac biomarkers were within the normal range; the high sensitive troponin I level was 82.6 ng/L (< 100 ng/L).
On day two of admission, the patient developed an episode of atrial fibrillation, which was resolved with two stat doses of verapamil 2.5 mg. The patient was treated with intravenous cefotaxime 2 g 8 hourly, where the blood culture was sensitive. Intravenous antibiotics were continued for six weeks, and the patient had a complete recovery. The follow-up blood cultures were negative and the 2D echocardiogram in six weeks did not show any vegetations or valvular defects, and the ejection fraction was more than 55%.