Emergency department point of care ultrasound utility in diagnosing infective endocarditis presenting as abdominal pain with bilateral iliac occlusion.

backgroundInfective Endocarditis (IE) is a life threatening disease which is relatively rare especially in young healthy adults, and patients can rapidly deteriorate due to valvular insufficiency; however diagnosis can be challenging in the Emergency Department (ED). CASE PRESENTATION: We present a case of a 37 year old male who attended the ED with fever, diarrhoea and abdominal pain for one week. On arrival, he was febrile and tachycardic with right iliac fossa tenderness. Computed Tomography scan of the Abdomen and Pelvis revealed splenic and left kidney infarcts with bilateral iliac artery thrombi. Bedside Point Of Care Ultrasound (POCUS) showed a large Mitral Valve vegetation which supported the diagnosis of infective endocarditis with septic emboli. The patient was given intravenous antibiotics, crystalloids and antipyretics. He was urgently referred to Cardiology and Cardiothoracic surgeons for definitive surgical management, and was subsequently intubated due to worsening hypoxia from acute valvular insufficiency complicated by heart failure. The same night, he underwent emergency mitral valve replacement and embolectomy of bilateral iliac arteries. Blood cultures grew Group B Streptococcus. During his stay, he developed multiple mycotic pseudoaneurysms and a left insular cortex infarct as complications from the septic emboli.

conclusionsThis patient had an atypical presentation of infective endocarditis in the ED, and bedside POCUS was one of the keys to the diagnosis. Although infective endocarditis is rare, emergency physicians should be aware of the diagnosis and its potential complications, and consider it in prolonged fever without a clear source. Bedside POCUS can be a valuable first-line imaging tool in the ED to rule in the diagnosis of IE, and to look for complications as well as indications for surgical intervention. Further research needs to be done to look at the sensitivity and specificity of POCUS compared to routine Transthoracic Echocardiogram/ Transoesophageal Echocardiogram.