Infective Endocarditis Causing Acute Myocardial Infarction

Abstract

Endocarditis is a well-known disease, yet septic embolization resulting in myocardial infarction is much rarer and very infrequently diagnosed in the emergency department (ED). Point-of-Care-Ultrasound (POCUS) can be used to confirm clinical suspicion within minutes of patient presentation, thereby expediting patient care. We report the case of a 26-year-old female with known intravenous drug use who presented with altered mental status. Her clinical presentation prompted urgent evaluation in the ED with POCUS which showed a hyperdynamic functioning left ventricle, greater than 50% inferior vena cava collapse, and a large tricuspid valve vegetation. In light of the electrocardiogram (ECG) ST changes suggesting an acute myocardial infarction, the patient was emergently taken to the cardiac catheterization laboratory where coronary angiography revealed multiple coronary emboli. Primary diagnoses included endocarditis due to Staphylococcus , septic pulmonary embolism, and ST-elevated myocardial infarction (STEMI) due to embolic occlusion of the distal left anterior descending artery. Myocardial infarction caused by septic embolization from endocarditis is a rare condition; however, POCUS is a quick, non-invasive tool that can aid the emergency medicine (EM) physician in identifying this life-threatening pathology thereby expediting appropriate care for the patient.

Multidisciplinary Perspectives of Challenges in Infective Endocarditis Complicated by Septic Embolic-Induced Acute Myocardial Infarction

“…It must also include treatment with bactericidal antibiotics for a long period [ 35 ]. Surgical embolectomy or emergency percutaneous thrombectomy, balloon, or stent angioplasty is recommended if thrombectomy fails [ 21 , 28 , 47 ]. Thrombolytic agents have often been used in ACS from septic emboli, but an increased risk of intracerebral hemorrhage due to associated mycotic cerebral infarcts has been observed [ 21 , 22 , 47 ].…”

“…Surgical embolectomy or emergency percutaneous thrombectomy, balloon, or stent angioplasty is recommended if thrombectomy fails [ 21 , 28 , 47 ]. Thrombolytic agents have often been used in ACS from septic emboli, but an increased risk of intracerebral hemorrhage due to associated mycotic cerebral infarcts has been observed [ 21 , 22 , 47 ]. Another rare cause of AMI without atherosclerotic plaque is extrinsic compression.…”

“…Coronary embolisms secondary to endocarditis with Enterococcus most commonly originating from the aortic valve have been previously reported, and they have been associated with LCX occlusion and papillary muscle rupture [ 22 ]. Some cases described infective endocarditis with rare embolization of the posterior descending artery [ 29 , 47 ]. Embolization in multiple arterial territories is also described in the literature, such as embolization from the aortic valve to the coronary arteries, concomitant with embolization to the arteries of the upper limbs [ 20 ] and embolization from the mitral valve to the cerebral, splenic, and spinal levels [ 4 ].…”

“…Specialized studies have confirmed that fungal endocarditis is more common in patients with prosthetic valves, indwelling venous catheters, post heart surgery, or in cases of immunocompromised patients, such as in the case of patients with IVDA. The guidelines recommend antimicrobial therapy, including intravenous antifungal medications, followed by the long-term use of a suppressive oral antifungal agent because of an increased risk of recurrence [ 25 , 47 ].…”

“…The initial blood cultures were positive for MSSA. Subsequently, the patient required continuous renal replacement therapy and a tracheostomy [ 47 ].…”