An interesting case of expressive aphasia: Enterococcus faecalis -related infective endocarditis complicating as septic emboli

Dear Editor We read with great interest the recent article by Wang etal.1 published at your esteemed journal. Through our recent experience, we would like to discuss few additional facts with regards to the neurological manifestations in infective endocarditis (IE). A 33-year-old male with past medical history of intravenous (IV) drug abuse, alcohol dependence and cigarette smoking for the past 15 years, presented with the symptoms suggestive of expressive aphasia. Magnetic resonance imaging (MRI) brain showed a large acute left parietal ischaemic stroke (Figure 1). Strong suspicion of IE was kept given his significant IV substance abuse history. 2D Echo was done which revealed moderate to severe mitral regurgitation with two mobile vegetations on the mitral valve measuring 1.2 × 1 and 1 × 1 cm approximately (Figure 1). Blood cultures grew Enterococcus faecalis in all four culture bottles within 24 h of incubation. Patient was initiated on IV antibiotics, ampicillin and ceftriaxone and underwent mitral valve replacement with 31 mm epic tissue valve. At follow-up, patient is doing well and completed a total duration of 6 weeks of antibiotics. (A) Computed tomography head showing evolving subacute infarct in the left middle cerebral artery (MCA) territory in left parietal lobe. (B, C) MRI brain T2 axial diffusion-weighted imaging (B) and T2 axial flair (C) showing acute left MCA territory infarct involving parietal region without haemorrhagic transformation. (D) 2D Echo showing vegetation on the tip of atrial surface of both the mitral leaflets of approximately 1.2 × 0.33 cm in maximum dimension. Every case needs to be evaluated for the possible need for surgical intervention. We congratulate Wang et al. for their meticulous diagnostic workup with neuroimaging in their patient which subsequently lead to the diagnosis of IE. We believe that presence of Staphylococcusaureus bacteraemia with an oscillating mass of 1 cm qualifies the author’s case for a Class I indication of surgical intervention as per the American College of Cardiology/American Heart Association guidelines. They also recommend early surgery (Class I) for persistent infection, heart block, valvular abscess or in case of a resistant organism (S.aureus, fungi etc.). Our case had a Class IIb indication surgical intervention and was successfully operated. This is to remind that any large mobile vegetation (>1 cm) on a native valve with or without evidence of embolic phenomenon qualifies as Class IIb indication for surgery.2 Role of neuro- and cardioimaging is well highlighted in both our and Wang et al.’s case.1 An interesting observation was noted by Hess et al. in their study over 100 patients in whom they did cerebral MRI and MR angiography within 7 days of admission.3 They found that 71.5% cases had evidence of MR-based parenchymal abnormalities along with either cerebral microbleeds (62 patients) or acute ischaemic lesions (40 patients) as the most frequent lesions. Hess et al.4 though did not find any significant correlation but proposed that any MRI finding of acute small infarcts of different ages in watershed territories and cortical cerebral microbleeds should be evaluated for the possibility of IE. Although author’s cases had a significant clinical improvement with medical management only; however, a follow-up echocardiography is necessary to know the status of oscillating mass. Enterococcus faecalis-related IE contributes to 5–20% of all IE cases.5 Our patient has successfully completed the antibiotic course and has minimal residual neuro deficits. To conclude, IE and similar cardiac anomalies can have varied presentations and awareness of these features would prompt early diagnosis and treatment.6,7 Conflict of interest: None declared.