A Clinical Challenge in the Emergency Department: A Case of Klebsiella Infective Endocarditis Presenting With Splenic Abscess.

Infective endocarditis (IE) is a serious bacterial infection of the endocardium and/or heart valves that carries considerable morbidity and mortality. Often presenting with very non-specific symptoms, this disease presents many challenges to the emergency medicine practitioner. A 47-year-old male with no pertinent medical history presented to the emergency department complaining of shortness of breath. He stated that his symptoms had been persistent for the last three weeks and were associated with malaise and fatigue. CT of the abdomen/pelvis with IV contrast revealed a 7-cm hypodensity of the spleen concerning for abscess versus infarct. He denied any trauma or IV drug use. Follow-up ultrasound was ordered, which characterized the hypodensity as a splenic abscess. An echocardiogram was recommended for possible IE, and cardiology was consulted. The transthoracic echocardiogram was performed on hospital day 2, which showed minimal mitral valve thickening with mild mitral regurgitation. The interventional radiology (IR) service was consulted for the splenic abscess in order to perform CT-guided drainage. An IR drain was successfully placed on hospital day 3. On the same day, blood cultures grew Klebsiella pneumoniae. On hospital day 5, that patient was transferred to the ICU for possible empyema formation with signs of respiratory distress. The patient underwent CT of the chest that showed the development of a left-sided effusion. The patient had also been persistently tachycardic and febrile, with high leukocytosis since admission and worsening respiratory status. Transesophageal echocardiogram (TEE) was scheduled but put on hold due to worsening respiratory status. Repeat TEE was scheduled five days later, which showed mitral regurgitation and increased size of the vegetation despite antibiotic therapy. Two days later, he was scheduled for mitral valve repair. When reviewing our case, the patient had both common and uncommon aspects of splenic abscess or IE. First, despite having respiratory symptoms for two weeks, the primary reason he came to the hospital was due to the new onset of fevers. He was febrile, tachycardic, and with significant leukocytosis. He continued to have fevers despite antibiotic therapy and IR drainage of the abscess. With no history of IV drug use history, negative transthoracic echocardiography, lack of immunocompromising condition, and blood cultures with gram-negative rods, IE became less likely of a diagnosis.  Establishing the diagnosis of IE proved to be exceptionally complicated, especially in the setting of a COVID-19 pandemic. The most notable challenge was having a high index of suspicion despite any risk factors. The patient was a previously healthy 47-year-old male with no medical problems. IE continues to be a clinical challenge for physicians, especially in the emergency department, due to the lack of diagnostic criteria such as positive blood cultures or vegetations visualized on echocardiographic studies. IE has a wide gamut of presentations with different levels of acuity. Diagnosis is more straightforward when patients present with obvious risk factors, but, in many cases, such as this one, those risk factors may be absent. A high index of suspicion is required, especially in patients with additional findings such as splenic abscess, embolic phenomenon, focal neurologic deficit, mycotic aneurysm, decompensated heart failure, new murmurs, or pleural effusions.