PUO- endocarditis

Intro:
Peter is a 80 y.o gentlemen who came to the hospital via ambulance due to an episode of uncontrollable rigors and SOB. This is in the setting of a previous pacemaker infection in October 2008.

HOPC

6 days ago, he had an episode of rigors that lasted about 20min. He was at home at that time and he started shaking uncontrollably with involved all of his limbs there was associated SOB, increase RR and feeling cold. No chest pains, palpitations. There was no associated neurological deficits- muscle weakness, numbness, visual changes. There was no LOC. During this episode he called the ambulance and was sent to the hospital. He recovered in the ambulance and was feeling tired but otherwise not confused. Prior to this episode he had two similar episodes while at home and while in hospital he developed a similar episode. The total number of attacks is 4.

Patient has no recent

· Fevers ( spiking (malaria), high swinging( abscesses), constant ( gen. bacterial/ neoplasia/CTD), intermittant fever (viral especially in paediatrics) ( (has chills and rigors)
· Fatigue, LOW(despite eating a lot), night sweats.
· Localised symptoms:
1. Cough, sputum(blood? Colour? Amt?), (SOB)
2. Chest pain, palpitations, PND, orthopnea, pillows used, peripheral odema (if HF)
3. urinary – freq, urgency, nocturia, dysuria, and incontinence
4. diarrhoea, constipation, abdominal pain, blood in stools
5. Neck stiffness, photophobia, Head ache
6. Arthralgia (backpain – epidural abscess), myalgia and skin rashes.
7. ear pain, face pain (sinusitis).
8. wounds/bites.

· Dentition
· Immunization – was up to date with both his pneumococcal and flu vaccine
· Contact – no contact with anyone that’s sick recently or anyone with TB
· Travel – gone to alice springs and NT but nothing too adventurous like swimming in rivers
· Occupation – purchasing manager
· Animals – No
· Drugs – later
· Sex- Nil.

Medical conditions

· Heart failure with AF was diagnosed in 2002. He presented with APO and was unable to sleep at night his wife had to send him in ED. A pace maker was then inserted in December 2002. Since then he does not complain of PND, orthopnea, uses 1 pillow, has occasional leg swelling well controlled by diuretics. His exercise tolerance is about 50m.
· October last year he noticed a rash on his skin overlying the pacemaker. Prior to this he developed a boil on his head when he bumped his head on the shower. His GP sent him to the hospital for further investigations and he was treated for a pacemaker infection with 1/12 of antibiotic treatment and the infection was presumed cleared.
· He had no other admissions for exacerbations for HF. His current HF meds are carvedilol, spironolactone, lasix.

Non-active medical conditions
· 2 hernia operations (1980)
· Right knee replacement (80’s)
· Backpain caused by lumber sacral spinal stenosis, which is getting worse recently. Still able to drive, no muscle weakness or numbness
· OSA(04’)- used to be on CPAP but doesn’t need to use it now.
· Bilateral varicose veins

CVD risk factors – HT, high cholesterol, No DM, smoked 16 pack/yrs and quit when he was 35.

Medications-
Carvedilol, spironolactome, lasix, lipitor, irbesatan, warfarin.
Was treated on ceftriaxone, flucoxicillin and vancomycin 3 days ago for empirical treatment of sepsis.

FH- NIL
Social – live, occupation, depression, financial, support, exercise, diet.

On physical examination

· Alert, well-orientated, no signs of fevers, rigors or sweats.
· V/S – 120/80 bp, 72 HR regular, sats 98%, temperature 37.7 at 0600hrs but previously afebrile.
· CVL in for 3 days – area of insetion not oedematous or red.
· Cannula on right arm.
· Pacemaker area not oedematous, no rash.

CVD exam – normal. Looking specifically for signs of IE – Janeway, oslers, splinter haemorrhage. Petechiae in the conjunctivae. Roth spots. Splenomegaly.

Resp- Normal

Abdomen – normal

Mx issues-
Identify source of infection – septic screen - sputum, stool, urine culture. CSF? CXR. Ideally 3 samples of bloods spaced at least 30min apart.
Empirical treatment for sepsis – antibiotics ( gentamycin+ ceftapine) + supportive therapy. This treatment does not cover for gram +ve -staphs aures, enterococci. [ use ampicillin or vancomysin], TB, PCP (co-trimaxazole, if allergic to sulphur meds use pentamidine), anaerobes(metronidazole). Consider fungal causes. If less sick ceftriaxone + stat dose of gentamycin is enough.