A late diagnosis of infective endocarditis (IE) in the Covid 19 Infection: A near fatal experience

Infective endocarditis (IE) is a notable cause of valvular dysfunction and heart failure among patients who have risk factors in the UK. It typically presents with fever associated with symptoms and signs of cardiac disease, in addition to its extracardiac manifestation which may indicate its severity.1 Co-infection of COVID-19 with IE could result in a diagnostic challenge as both conditions are proinflammatory and can lead to delays in effecting goal directed management for IE. In Covid 19 pandemic, it has become common for diagnosis of IE to be missed.2 Detailed clinical evaluation is therefore important in clinching its diagnosis. Our patient is a 75-year-old man with a background of chronic obstructive pulmonary disease (COPD) as well as significant smoking history. Presented with a history of poor oral intake, weight loss, and recent diagnosis of Covid 19 with ongoing fever on admission. Patient has been covid 19 positive for about 3 weeks prior to hospitalisation. Symptoms were attributed to Covid 19 infection and had multiple antibiotics treatments at home for COPD exacerbation. He was referred to the hospital for further evaluation because he remained unwell. Initial examination revealed clinical evidence of pulmonary hypertension and tricuspid regurgitation (TV) which was believed to be related to COPD. Initial blood tests revealed an increase in inflammatory markers. He was started on antibiotics and oxygen, treated as infective COPD exacerbation. On transfer to Cardiology ward 5 days later, A finding of splenic infarction and pulmonary embolus on radiologic images performed 3 weeks prior to admission revealed a missed diagnosis of extracardiac manifestation of IE using the modified Duke criteria.3 High suspicions as well as persistence of symptoms prompted further investigation including three sets of blood culture (BC) and transthoracic echocardiography (TTE). Enterococcus faecalis was isolated from BC (7 days from admission). Echocardiography revealed large vegetations in the tricuspid valves (TV) with severe tricuspid regurgitation (TR) as well as a vegetation in the right coronary cusp of the aortic valve Final diagnosis was a case of IE with several extracardiac complications.3,4 Colonic malignancy was a differential in this case. Enterococcus faecalis is reported as the third commonest cause of IE and has been described in patients with colonic tumours. Intravenous amoxicillin and gentamicin were prescribed, based on microbiologic sensitivity and according to local trust guidelines. Symptoms however persisted despite treatment, including a new onset heart failure which necessitated patient's referral for surgery Patient declined surgery at that point as he had deteriorated further and became clinically unfit for surgery. He requested for palliative treatment and was discharged home subsequently as end-of-life care.