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Subarachnoid hemorrhage as the key to the diagnosis

Published:September 06, 2021DOI:https://doi.org/10.1016/j.ejim.2021.08.017

      Keywords

      1. Case description

      A 70-year-old woman was admitted at the emergency department due to abdominal pain progressing over the last six hours. She had been feeling sick for the last month, with nausea and persistent fever. Initial work-up revealed mild anemia, elevated inflammatory markers and an unremarkable abdominal ultrasound. While at the emergency department, she suddenly progressed to coma, with admission to the intensive care unit. Both cranial CT scan and angiography were conducted, showing a cortical artery aneurysm surrounded by a sulcal subarachnoid hemorrhage on the left parietal convexityFig. 1. What is your diagnosis for this patient?

      2. Discussion

      With findings suggestive of a small mycotic aneurysm, a diagnosis of infective endocarditis was considered and later confirmed by transesophageal echocardiogram, which showed an aortic valve vegetation with severe aortic insufficiency and a mitral valve abscess with anterior leaflet rupture. Blood cultures identified Streptococcus parasanguinis as the infection culprit. The patient was transferred to a cardiac surgery center for timely surgical management.
      Neurological manifestations (like transient ischemic attacks, ischemic or hemorrhagic strokes, cerebral microbleeds, cerebral abscesses, mycotic aneurysms, meningitis or toxic encephalopathies) are present in 40% of diagnosed cases of infective endocarditis (IE), being reported as the presenting symptom in nearly half of these patients [
      • Heiro M.
      • Nikoskelainen J.
      • Engblom E.
      • et al.
      Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.
      ].
      Within patients with neurological complications of IE, 12–30% present cerebral hemorrhages due to: hemorrhagic transformation of ischemic strokes caused by septic emboli, rupture of mycotic aneurysms or vasculitis-induced cerebral microbleeds [
      • Heiro M.
      • Nikoskelainen J.
      • Engblom E.
      • et al.
      Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.
      ,
      • Asif T.
      • Mohiuddin A.
      • Hasan B.
      • Masoud A.
      Infective endocarditis presenting as subarachnoid hemorrhage: an appeal for caution.
      ].
      Mycotic aneurysms are present in 2–4% of IE patients [
      • Sotero F.D.
      • Rosário M.
      • Fonseca A.C.
      • Ferro J.M.
      Neurological complications of infective endocarditis.
      ], being typically located on the peripheral branches of the middle cerebral artery. They usually do not produce symptoms until they rupture, originating subarachnoid, intracranial or intraventricular hemorrhages [
      • Sotero F.D.
      • Rosário M.
      • Fonseca A.C.
      • Ferro J.M.
      Neurological complications of infective endocarditis.
      ].
      In patients presenting with non-specific constitutional symptoms, identification of cerebral hemorrhage on CT scan and mycotic aneurysms on vessel imaging techniques (intra-arterial cerebral angiography, CT or MR angiography) can help guiding clinical reasoning towards the final diagnosis of an infective endocarditis.
      Fig 1
      Fig. 1CT scan: axial view; CT Angiography: axial and sagittal views, respectively.

      References

        • Heiro M.
        • Nikoskelainen J.
        • Engblom E.
        • et al.
        Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.
        Arch Intern Med. 2000; 160: 2781-2787https://doi.org/10.1001/archinte.160.18.2781
        • Asif T.
        • Mohiuddin A.
        • Hasan B.
        • Masoud A.
        Infective endocarditis presenting as subarachnoid hemorrhage: an appeal for caution.
        Cureus. 2017; 9: e1176https://doi.org/10.7759/cureus.1176
        • Sotero F.D.
        • Rosário M.
        • Fonseca A.C.
        • Ferro J.M.
        Neurological complications of infective endocarditis.
        Curr Neurol Neurosci Rep. 2019; 19: 23https://doi.org/10.1007/s11910-019-0935-x