1. CLINICAL PROBLEM SOLVING
17-year-old girl with high fever and rash
Maja Vrdoljak, MD
University Hospital for Infectious Diseases, Zagreb

2. HISTORY 17-year-old girl sudden onset of high fever up to 39,9 °C
pain in all extremities, headache
onset of rash on palms and soles
malaise; inability to walk

3. History and physical examination
Previously healthy girl; acne vulgaris
Lives with parents (Bosnia), attends school; contacts are healthy
Physical examination:
T ax 37.9 °C, HR 112/min, BP 105/65 mmHg, RR 20/min, GCS 15
Skin: erythematous macules and petechiae on palms and soles, pustules; subungual hemorrhagiae
Heart: systolic murmur 2/6 over the mitral valve
Probable diagnosis:
Enteroviral disease
Infective endocarditis
Meningococcal disease
Sepsis
Chickenpox

4. CORRECT ANSWER Probable diagnosis: Enteroviral disease
Infective endocarditis
Meningococcal disease
Sepsis
Chickenpox

5. QUESTION Your next step: Blood cultures Lab tests Echocardiogram
Chest x-ray
All of the above

6. CORRECT ANSWER Your next step: Blood cultures Lab tests Echocardiogram
Chest x-ray
All of the above

7. DIAGNOSIS Echocardiogram: Diagostic tests results:
vegetation 7x6 mm on the mitral valve
mitral regurgitation grade II
EF 70%
Diagostic tests results:
CRP mg/L
WBC 20.5/μL with 91,1% of neutrophils
E 3.92 x10¹²/L, Hgb 102 g/L
PLT 42 x10⁹/L
PT 42%
Chest x-ray – no pathology

8. QUESTION
Which pathogens do you expect most commonly in blood cultures:
K. pneumoniae
E. coli
staphylococci, streptococci or enterococci
P. aeruginosa
funghi

9. CORRECT ANSWER
A minimum of three blood cultures from separate venipunctures should be obtained!
Which pathogens do you expect most commonly in blood cultures:
K. pneumoniae
E. coli
staphylococci, streptococci or enterococci
P. aeruginosa
funghi

10. QUESTION Which empiric therapy should you choose: ceftriaxone
meropenem
gentamicin
vancomycin
amphotericin B

11. CORRECT ANSWER Which empiric therapy should you choose: ceftriaxone
meropenem
gentamicin
vancomycin
amphotericin B

12. TREATMENT and OUTCOME Diagostic tests results:
3 sets of blood cultures: Staphylococcus aureus (R penicilin)
Treatment:
flucloxacillin, 6 weeks in total
symptomatic measures – erythrocytes and platelet transfusions, FFP, human albumins…
Outcome:
complete resolution of vegetation
no long-term sequelae

13. QUESTION Which complications could you expect: heart failure
perivalvular abscess
arrhythmia
metastatic infections due to septic emboli
All of the above

14. CORRECT ANSWER Which complications could you expect: heart failure
perivalvular abscess
arrhythmia
metastatic infections due to septic emboli
All of the above

15. SUMMARY indwelling central lines presence of prosthetic material
Infective endocarditis (IE) should be suspected in febrile patients with:
preexisting heart disease
indwelling central lines
presence of prosthetic material
persistent bacteremia
infection with organisms most associated with IE
heart murmur
Blood cultures (at least 3 sets) should be obtained as quickly as possible so targeted antibiotic therapy can be started.

16. SUMMARY
Empiric therapy should cover staphylococci (methicillin susceptible and resistant), streptococci, and enterococci.
Sometimes surgical intervention is required.
Why is the IE so dangerous?
Complications:
Heart failure, valvular insufficiency, arrhythmia, atrioventricular heart block
Metastatic infections due to septic emboli (osteomyelitis, pneumonia, distal abscesses in the kidneys, spleen…)
Neurologic complications - embolic stroke, intracerebral hemorrhage, brain abscess, SAH, meningitis
HIGH MORTALITY RATE