SAEM Boston 2003 CPC PresentationSAEM Boston 2003 CPC Presentation

Jeff Hurley MDJeff Hurley MDEmergency MedicineEmergency Medicine

Martin Luther King HospitalMartin Luther King HospitalCharles Drew UniversityCharles Drew University

HistoryHistory

CC: Left sided weakness, facial droop, and difficulty CC: Left sided weakness, facial droop, and difficulty speaking X 4 hoursspeaking X 4 hours

HPI: 53 yo Hispanic male with PMH of diabetes HPI: 53 yo Hispanic male with PMH of diabetes mellitus type II, hypertension, and “heart trouble” mellitus type II, hypertension, and “heart trouble” was brought in by paramedics with a complaint of was brought in by paramedics with a complaint of weakness on the left side of his body including weakness on the left side of his body including difficulty controlling his mouth and difficulty difficulty controlling his mouth and difficulty speaking over the last 4 hours.speaking over the last 4 hours.

History ContinuedHistory Continued Patient states that he was in a jacuzzi when all of a sudden he Patient states that he was in a jacuzzi when all of a sudden he

started feeling weak and dizzy. When he attempted to walk, started feeling weak and dizzy. When he attempted to walk, he noted that he had decreased strength and coordination. He he noted that he had decreased strength and coordination. He also noted that he that he had some difficulty speaking clearly also noted that he that he had some difficulty speaking clearly and was drooling. In addition, the patient complained of a low and was drooling. In addition, the patient complained of a low severity non-radiating dull chest pain worse with inspiration, severity non-radiating dull chest pain worse with inspiration, some shortness of breath, and a headache since being in the some shortness of breath, and a headache since being in the jacuzzi. The patient went home and decided to take some jacuzzi. The patient went home and decided to take some Tylenol, and when that didn’t resolve his symptoms, he Tylenol, and when that didn’t resolve his symptoms, he became concerned and called EMS.became concerned and called EMS.

History ContinuedHistory Continued

In the previous ten days he states that he has In the previous ten days he states that he has had fever and chills, and over the last two had fever and chills, and over the last two months, greater than 20 pounds of weight loss. months, greater than 20 pounds of weight loss. He also states that he has had increasing back He also states that he has had increasing back pain over the last two weeks. The patient pain over the last two weeks. The patient denied the presence of any diplopia, seizure denied the presence of any diplopia, seizure disorder, nausea, vomiting, diaphoresis, or disorder, nausea, vomiting, diaphoresis, or palpitations.palpitations.

History ContinuedHistory Continued PMH: PMH:

Diabetes x 20 yearsDiabetes x 20 years Hypertension x 10 yearsHypertension x 10 years Low back pain x 30 yearsLow back pain x 30 years

PSH:PSH: Anterior cervical discectomy and fusion of C5-C6 for spinal stenosis 5 weeks Anterior cervical discectomy and fusion of C5-C6 for spinal stenosis 5 weeks

agoago Carpal tunnel release 6 years agoCarpal tunnel release 6 years ago

Meds: Meds: Glipizide 5 mg QDGlipizide 5 mg QD Lotensin 10 mg QDLotensin 10 mg QD

Allergies:Allergies: NKDANKDA

History ContinuedHistory Continued

SH:SH: Smokes ½ to 1 pack per day for 35-40 yearsSmokes ½ to 1 pack per day for 35-40 years Few beers a day for 20 yearsFew beers a day for 20 years Denies illicit drug useDenies illicit drug use

FH:FH: Diabetes: Parents and siblingsDiabetes: Parents and siblings

ROS:ROS: Otherwise negativeOtherwise negative

PhysicalPhysical Vitals: Vitals:

Temp: 99.9 Tmax: 103.0 HR: 89 BP: 138/80 RR: 20 Pulse Ox: 99%Temp: 99.9 Tmax: 103.0 HR: 89 BP: 138/80 RR: 20 Pulse Ox: 99% General: General:

Well developed, slightly emaciated, no acute distress, dysarthic speechWell developed, slightly emaciated, no acute distress, dysarthic speech HEENT:HEENT:

ATNC, PERRLA, EOMI, no nystagmus, no lymphadenopathy, ATNC, PERRLA, EOMI, no nystagmus, no lymphadenopathy, Neck:Neck:

Supple, normal ROM, no JVD, no bruits, mature surgical scar left anterior triangleSupple, normal ROM, no JVD, no bruits, mature surgical scar left anterior triangle Heart:Heart:

RRR, Grade III/VI diastolic murmur at LSB 5th intercostal space with radiation to the left RRR, Grade III/VI diastolic murmur at LSB 5th intercostal space with radiation to the left axillaaxilla

Lungs:Lungs: Clear, with good tidal volume Clear, with good tidal volume

Abd:Abd: Soft, NT, ND, positive bowel sounds, normal rectal tone, guiac negativeSoft, NT, ND, positive bowel sounds, normal rectal tone, guiac negative

Ext:Ext: pulses +2, no edemapulses +2, no edema

Physical ContinuedPhysical Continued Back: Back:

Tenderness to palpation in the low backTenderness to palpation in the low back Neuro: A&O x4Neuro: A&O x4

Cranial Nerves: Visual fields intact, EOMI, slightly decreased pinprick on left Cranial Nerves: Visual fields intact, EOMI, slightly decreased pinprick on left side of face, otherwise sensory intact, facial droop on the left with the frontalis side of face, otherwise sensory intact, facial droop on the left with the frontalis muscle preserved, hearing intact, good gag reflex, SCM and trapezius normal muscle preserved, hearing intact, good gag reflex, SCM and trapezius normal strength, hypoglossal intactstrength, hypoglossal intact

Motor: 4/5 strength left upper extremity and left lower extremity, 5/5 strength Motor: 4/5 strength left upper extremity and left lower extremity, 5/5 strength on the righton the right

Sensory: slightly decreased pinprick sensation on left upper and lower Sensory: slightly decreased pinprick sensation on left upper and lower extremityextremity

Cerebellar: Finger to Nose: decreased with left arm, Heel to Shin: bilateral Cerebellar: Finger to Nose: decreased with left arm, Heel to Shin: bilateral disorganization of movement (possibly secondary to back pain)disorganization of movement (possibly secondary to back pain)

Gait: antalgic, slight limp, otherwise narrowGait: antalgic, slight limp, otherwise narrow

Laboratory

• Differential: – 64.5% PMNs, 22.5% Lymphs, 10.0% Monos, 1.3% Eosinophils

• PT: 13.3 • PTT: 29.4 • INR: 1.2• UA: no white cells, leukocyte esterase and nitrate

negative• ESR: 57

EKGEKG

ImagingImaging

Chest X-Ray: Read as normalChest X-Ray: Read as normal

Noncontrast Head CT: (image lost)Noncontrast Head CT: (image lost) Triangular sharp low attenuation area, Triangular sharp low attenuation area,

approximately 2 cm, with edema/hemorrhage approximately 2 cm, with edema/hemorrhage located right parietal lobe superiorlylocated right parietal lobe superiorly

EndEnd

DiagnosisDiagnosis

1: Multiple acute cerebral vascular1: Multiple acute cerebral vascular

accidents secondary to septic emboliaccidents secondary to septic emboli

from infective endocarditisfrom infective endocarditis

2: Discitis2: Discitis

3: Paraspinal Abscess3: Paraspinal Abscess

Septic Embolism

Septic Embolism

Disease ProcessDisease Process Infective endocarditis: Infection of the endocardial Infective endocarditis: Infection of the endocardial

surface of the heartsurface of the heart cardinal lesion is the vegetationcardinal lesion is the vegetation bacteremia, adherence, invasion and growthbacteremia, adherence, invasion and growth ineffective immunological responseineffective immunological response

poor vascular supplypoor vascular supply decreased complement abilitydecreased complement ability fibrin depositionfibrin deposition

usually occurs in high risk conditionsusually occurs in high risk conditions nonbacterial thrombotic endocarditis (NBTE)nonbacterial thrombotic endocarditis (NBTE)

vasculitis, renal failure, neoplasmvasculitis, renal failure, neoplasm prosthetic heart valve, Hx of endocarditis, congenital lesions, prosthetic heart valve, Hx of endocarditis, congenital lesions,

rheumatic heart disease, mitral valve prolapse, hypertrophic rheumatic heart disease, mitral valve prolapse, hypertrophic cardiomyopathycardiomyopathy

Disease ProcessDisease Process AcuteAcute

Different etiological causes due to predisposing factorsDifferent etiological causes due to predisposing factors IVDA: most commonly IVDA: most commonly Staph. aureusStaph. aureus. Acute. Acute

TalcTalc Normal valves / Right-SidedNormal valves / Right-Sided HACEK (HACEK (Haemophilus aphrophilus, Actinobacillus, Cardiobacterium hominis, Eikenella Haemophilus aphrophilus, Actinobacillus, Cardiobacterium hominis, Eikenella

corrodens, Kingella kingaecorrodens, Kingella kingae)) usually subacuteusually subacute large-vessel septic embolilarge-vessel septic emboli

P. aeroginosaP. aeroginosa Prosthetic Valve: Prosthetic Valve: Staph. aureusStaph. aureus..

More likely with mechanicalMore likely with mechanical Fever likelyFever likely Murmur maybe difficult to detectMurmur maybe difficult to detect May infect previously normal valvesMay infect previously normal valves Less likely to have vasculitic lesionsLess likely to have vasculitic lesions Right sided emboli to lungs Right sided emboli to lungs

Disease ProcessDisease Process SubacuteSubacute

Predisposing factorPredisposing factor Mitral most commonMitral most common AorticAortic Mitral and AorticMitral and Aortic TricuspidTricuspid Rarely involves pulmonary valveRarely involves pulmonary valve

Streptococcus speciesStreptococcus species Most common Most common Strep. viridians, Strep. viridians, Coagulase Negative Strep, Coagulase Negative Strep, EnterococcusEnterococcus

Origin: dental, skin, GI, GUOrigin: dental, skin, GI, GU HACEKHACEK Immunological / vasculitic phenomena usually presentImmunological / vasculitic phenomena usually present More likely to have a murmur detectableMore likely to have a murmur detectable Systemic embolizationSystemic embolization

Disease ProcessDisease Process

Special CasesSpecial Cases Fungal endocarditisFungal endocarditis

Candida and AspergillusCandida and Aspergillus Consider in immunocompromised or Consider in immunocompromised or

immunosuppressedimmunosuppressed HIV, IVDA, chemotherapyHIV, IVDA, chemotherapy

Bartonella speciesBartonella species Homeless males with terrible hygieneHomeless males with terrible hygiene

Disease ProcessDisease Process

ComplicationsComplications Valvular insufficiencyValvular insufficiency

CHFCHF Embolic phenomenaEmbolic phenomena

SterileSterile SepticSeptic

DeathDeath

RelevanceRelevance

Rare diseaseRare disease Incidence of 2-4 per 100,000Incidence of 2-4 per 100,000 Underlying etiology has changedUnderlying etiology has changed

rheumatic heart disease has decreasedrheumatic heart disease has decreased prosthetic valves has increasedprosthetic valves has increased aortic stenosisaortic stenosis

““Can’t miss” diagnosisCan’t miss” diagnosis Untreated IE: FatalUntreated IE: Fatal Treated native valve IE: approximately 20%Treated native valve IE: approximately 20% Treated prosthetic valve IE: 20-60%Treated prosthetic valve IE: 20-60%

ED EncounterED Encounter Fever and local neuro findingsFever and local neuro findings Non-anatomical lesion:Non-anatomical lesion:

Ipsilateral findings of left facial droop and left sided weakness suggest Ipsilateral findings of left facial droop and left sided weakness suggest cortex involvement prior to decussationcortex involvement prior to decussation

However not consistent with the motor homonucleus based on size of However not consistent with the motor homonucleus based on size of the lesion and locationthe lesion and location

Suggested multiple lesionsSuggested multiple lesions MRI Reading:MRI Reading:

Focal high diffusion weighted signal lesions suggestive of acute Focal high diffusion weighted signal lesions suggestive of acute infarctions:infarctions:

right basal ganglion, right frontal lobe, and right parietal loberight basal ganglion, right frontal lobe, and right parietal lobe Focal hemorrhagic acute infarction was prominent in the right parietal Focal hemorrhagic acute infarction was prominent in the right parietal

lobe with ring enhancement suggestive of an infectious etiologylobe with ring enhancement suggestive of an infectious etiology

Parietal Lesion / Basal Ganglia

Frontal Lesion

ED EncounterED Encounter Classic triad for infective endocarditis: Classic triad for infective endocarditis:

fever (intermittent)fever (intermittent) anemiaanemia heart murmurheart murmur

Common findings:Common findings: weaknessweakness headacheheadache chest pain (pleuritic)chest pain (pleuritic) shortness of breathshortness of breath anorexiaanorexia

Absence of vasculitic findings:Absence of vasculitic findings: no Roth spots, Osler nodes, Janeway lesions, splinter hemorrhagesno Roth spots, Osler nodes, Janeway lesions, splinter hemorrhages suggested an acute as opposed to a subacute etiologysuggested an acute as opposed to a subacute etiology concern of a post-operative infectionconcern of a post-operative infection

Transthoracic Echocardiogram TTE:Transthoracic Echocardiogram TTE:Longitudinal Apex ViewLongitudinal Apex View

Transthoracic Echocardiogram Demonstrated thickening of the mitral valve leaflet with vegetation

ED EncounterED Encounter

Acute versus SubacuteAcute versus Subacute AcuteAcute

No vasculitic changes notedNo vasculitic changes noted Acute more likely to embolizeAcute more likely to embolize History of recent surgery History of recent surgery

SubacuteSubacute History of heart troubleHistory of heart trouble EKG: left atrial enlargement, left ventricular EKG: left atrial enlargement, left ventricular

hypertrophyhypertrophy Left-sided murmurLeft-sided murmur

EKG: PVCs, LVH, LAEEKG: PVCs, LVH, LAE

MRI Cervical Spine

MRI Lumbar Spine: Discitis

Discitis

Paraspinal Abscess

OutcomeOutcome Patient improved greatly during hospital stayPatient improved greatly during hospital stay Started on vancomycin, gentamycin, and ceftriaxone in the Started on vancomycin, gentamycin, and ceftriaxone in the

emergency departmentemergency department Blood cultures positive on day #2 for Blood cultures positive on day #2 for Strep. ViridiansStrep. Viridians

Meeting Duke’s criteria: Two MajorMeeting Duke’s criteria: Two Major Major: blood cultures, endocardial vegetation (did not meet new Major: blood cultures, endocardial vegetation (did not meet new

regurgitation criterion)regurgitation criterion) Minor: fever, arterial emboliMinor: fever, arterial emboli

Repeat blood cultures were negative in two daysRepeat blood cultures were negative in two days Patient transferred to rehabilitation center for IV Abx.Patient transferred to rehabilitation center for IV Abx. Unfortunately within the last two months, the patient returned Unfortunately within the last two months, the patient returned

to the ED with acute onset of painless monocular loss of to the ED with acute onset of painless monocular loss of vision and was diagnosed with central retinal artery occlusion. vision and was diagnosed with central retinal artery occlusion.

Resolution of Facial DroopResolution of Facial Droop

ReferencesReferences

Marx JA et al. Marx JA et al. Rosen’s Emergency MedicineRosen’s Emergency Medicine Concepts and Clinical PracticeConcepts and Clinical Practice 5 5thth ed. Mosby. ed. Mosby. St. Louis 2002.St. Louis 2002.

Pelletier, L Jr. Pelletier, L Jr. Infective EndocarditisInfective Endocarditis. . www.emedicine.comwww.emedicine.com May 16, 2003. May 16, 2003.