SHM Converge Scientific Abstract ePoster Gallery-Anchors Away!

Pdf Summary

This case describes a 66-year-old man with neuromyelitis optica on rituximab, atrial fibrillation, paraplegia, a chronic urinary catheter, and a history of recurrent multidrug-resistant infections, including prior prosthetic joint infection. He presented with fever and purulent urine, and because he was insensate below the umbilicus, dysuria could not be assessed. Initial evaluation focused on urinary tract infection and possible pneumonia, with chest imaging showing nonspecific opacities. He was started on meropenem and vancomycin. Blood cultures later grew MRSA, while urine cultures grew Pseudomonas.<br /><br />Despite treatment, fevers persisted, and attention shifted to his knee because of his history of prosthetic joint infection with MRSA and Pseudomonas. Orthopedics attempted aspiration unsuccessfully, and antibiotics were changed to daptomycin and ceftaroline. An echocardiogram that had been ordered earlier was read later and revealed a large 4.2 x 1.6 cm mitral valve vegetation, confirming infective endocarditis.<br /><br />Before this result was recognized, a medical student noticed new slurred speech and left-sided weakness. The patient underwent emergent stroke evaluation, which demonstrated subarachnoid hemorrhage in the left central sulcus, a left occipital infarct, and a right hypothalamic infarct. These findings raised concern for complications of infective endocarditis, including possible mycotic aneurysm.<br /><br />Cardiothoracic surgery was consulted but the patient was not a surgical candidate because of the intracerebral hemorrhage. Neurosurgery planned cerebral angiography to evaluate for a mycotic aneurysm. Ultimately, the patient and family chose comfort-focused care.<br /><br />The main teaching points were that anchoring bias can delay recognition of serious disease, persistent infection should prompt early consideration of infective endocarditis, and earlier diagnosis in this case might have allowed intervention before catastrophic neurologic complications developed.

Asset Subtitle

Mohammed Hindi

Meta Tag

Author List John Romond, Mohammed Hindi

Category Clinical Vignettes

Concept Infective Endocarditis

Concept Anchoring Bias

Concept Mitral Valve Vegetation

Concept Modified Duke Criteria

Concept Persistent Infection

Distinguished Non-Finalist

Presenter Organization University of Kentucky

Presenting Author Mohammed Hindi

Track Adult

Keywords

infective endocarditis

MRSA bacteremia

mitral valve vegetation

mycotic aneurysm

subarachnoid hemorrhage

ischemic stroke

anchoring bias

prosthetic joint infection

multidrug-resistant infection

neuromyelitis optica

Infective Endocarditis

Anchoring Bias

Mitral Valve Vegetation

Modified Duke Criteria

Persistent Infection