A Diagnostic Labyrinth: From Focal Neurological Deficits to Vegetative Valvular Disease

Introduction: Infective endocarditis (IE) is a clinical chameleon with diverse neurological manifestations. While embolic ischemic stroke is well-recognized, isolated cortical subarachnoid hemorrhage (cSAH) and limb-shaking phenomena as presenting features remain rare and diagnostically elusive. Case Description: A 66-year-old hypertensive male presented with a 20-day febrile illness and acute-onset involuntary movements, right upper limb weakness, numbness, and cerebellar ataxia. Examination revealed bradyphrenia, bilateral spasticity with muscle wasting, right-sided dysmetria, ataxic gait, and terminal neck rigidity. Initial differential diagnoses included limb-shaking transient ischemic attack, focal seizure, and acute stroke. Computed tomography (CT) brain identified a localized left central sulcus cSAH with adjacent cortical edema; CT angiography was unremarkable. Magnetic resonance imaging brain with venogram demonstrated diffuse hypertensive microangiopathy and excluded cortical venous thrombosis. Cerebrospinal fluid (CSF) analysis revealed pleocytosis and elevated red blood cells, suggesting meningitis or SAH. Electroencephalogram did not show any epileptiform activity. Systemic evaluation revealed hepatosplenomegaly, anemia, and hypothyroidism. Crucially, echocardiography demonstrated multiple vegetations on both mitral leaflets with mild regurgitation, establishing IE as the unifying diagnosis. Blood cultures were sent per Duke Criteria protocol and antimicrobial therapy was optimized. Digital subtraction angiography ruled out the possibility of mycotic aneurysm. Discussion: The cSAH likely resulted from hemorrhagic transformation of a septic embolic infarct rather than mycotic aneurysm rupture. The limb-shaking episodes represented focal motor seizures secondary to cortical irritation from adjacent blood and edema. CSF pleocytosis reflected sympathetic meningitis from septic emboli. Hepatosplenomegaly and anemia were consistent with subacute bacterial endocarditis. Conclusion: This case highlights that atypical cSAH in a febrile patient mandates cardiac evaluation. A multidisciplinary approach integrating echocardiography, neuroimaging, and cultures is essential for timely diagnosis. Publication History Article published online: 15 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India