A case of Wegener granulomatosis as a cause for fever of unknown origin (FUO) and secondary involvement of endocardium in association with mitral valve prosthesis is presented. Although the patient was referred as a case of unresolving pneumonia, her unresponsiveness to broad spectrum antibiotics including infective endocarditis treatment prompted investigation for a non-infectious aetiology for her FUO, leading to a diagnosis of Wegener granulomatosis.
A 36-year-old male, car driver, with no significant past medical history was brought in altered sensorium of one day duration. He had a prodrome of headache and fever preceding this for 3 days. He also had an episode of seizures of generalized tonic-clonic type. There was no history of trauma. His GCS was 14, E4V4M6. He was in altered sensorium and agitated. Cranial, motor and sensory nervous system examination was normal. Kernig's and Brudzinski were positive. Diagnosis of Meningo-encephalitis was considered. Blood investigations were normal. Imaging showed T2W and FLAIR hyperintensities, restricted diffusion and patchy enhancement post contrast in bilateral medial temporal lobe (L>R) [Table/ Fig-1], the left insular cortex [Table/ Fig-2], bilateral inferior frontal lobes (L>R) and bilateral cingulate gyri. Electroencephalogram revealed sharp wave discharge in T4 to T6 leads. Cerebrospinal fluid analysis was predominantly lymphocytic with high protein and low-normal glucose. Diagnosis of Herpes simplex virus (HSV) encephalitis was strongly considered. He was started on I.V acyclovir impending CSF analysis culture and Polymerase Chain Reaction (PCR) reports. Patient continued to have fever, He later developed global aphasia and his GCS worsened to 9, E4V1M4. His power decreased to 3/5 in the lower limbs. In the milieu of his worsening clinical condition,
A 23-year old male of South-Asian ethnicity, presented with fever and cough of one month duration. Examination revealed pansystolic murmur in tricuspid area, ejection systolic murmur in pulmonary area and a normal second heart sound. Echocardiogram showed tricuspid valve vegetations with mild to moderate Pulmonary artery hypertension (PAH) with non dilated right atrium and right ventricle. Blood Cultures for typical and atypical organisms of endocarditis were sterile. Anti-nuclear antibody (ANA) turned out to be positive but ds-DNA and anti-sm were negative. Lupus anticoagulant and anti cardiolipin antibody were positive in high titers. CECT thorax revealed thrombotic occlusion of left main pulmonary artery (LMPA). Criteria for Systemic lupus erythematosus (SLE), was not met initially, developed subsequently during the course of the disease. He was finally diagnosed as Anti-Phospholipid Antibody Syndrome (APS) secondary to SLE. This is a rare case of APS presenting as right sided endocarditis in a young male. Initially confused for Infective Endocarditis but finally diagnosed as APS secondary to SLE.
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