Aggressive enteral opioid therapy and withdrawal adjuncts, alongside timely source control via prosthetic mitral valve replacement, contributed to a satisfactory neurologic outcome.
Case Report (n=1)
No
Timely surgical source control and aggressive management of severe opioid withdrawal can lead to full neurological recovery in complex prosthetic valve endocarditis.
Abstract Introduction Prosthetic valve endocarditis (PVE) is a quickly expanding complication as the overall prevalence of prosthetic valves increases. PVE vegetations are often large and mobile resulting in increased risk of emboli as well as increased risk of intracerebral hemorrhage (ICH) due to anti-coagulation. These conditions are often associated with intravenous drug abuse (IVDA), so aggressive prevention and treatment of withdrawal is essential to preserve a functional neurologic status. Description An unidentified male presented to our hospital encephalopathic. Upon evaluation the patient was notably septic with a fresh, well-healing sternotomy incision. Additionally, there was evidence of IVDA, and the patient received a clinical opiate withdrawal score (COWS) of 21. CT scan of his head, neck, chest, abdomen and pelvis showed right frontotemporal edema, multi-focal pneumonia, and lesions concerning for splenic and renal infarcts. In addition to routine sepsis care, he was treated with hydromorphone, ondansetron, clonidine, and dexmedetomidine. TTE revealed a large, highly mobile vegetation on his prosthetic mitral valve. MRI brain revealed several areas of acute infarction and several other enhancing lesions consistent with resolving abscess or infarction. Despite ongoing care, subsequent head CTs and MRIs showed numerous new infarctions as well as small areas of sub-arachnoid hemorrhage. He was ultimately intubated for worsening encephalopathy. Blood cultures grew Methicillin-resistant Staphylococcus aureus, and the patient was stabilized on vancomycin, meropenem, and rifampin. After a prolonged period of hemodynamic instability, poor vent weaning, and persistent bacteremia, he underwent prosthetic mitral valve explant followed by replacement. After replacement, he rapidly improved and was extubated. Though deconditioned, the patient had no neurological deficits and had normal cognitive function. He was discharged on a short course of opioids, gabapentin, clonazepam with a plan to initiate buprenorphine or methadone. Discussion In this case, there were numerous sources for potential neurologic injury including metabolic encephalopathy from sepsis, severe substance withdrawal, and intracranial lesions. While timely source control for his sepsis and emboli was the foundation to recovery, his recovery was complicated by severe opioid withdrawal. Throughout his 48 Day ICU course, early and aggressive enteral opioid therapy and withdrawal adjuncts reduced his infusion requirements and contributed to a satisfactory neurologic outcome. This abstract is funded by: None
Collins et al. (Fri,) conducted a case report in Prosthetic valve endocarditis complicated by cerebral infarction and severe opioid withdrawal (n=1). Prosthetic mitral valve replacement, antibiotics, and aggressive opioid withdrawal management was evaluated. Aggressive enteral opioid therapy and withdrawal adjuncts, alongside timely source control via prosthetic mitral valve replacement, contributed to a satisfactory neurologic outcome.