Because of the COVID19 pandemic, you are practicing medicine by telemedicine. You are interviewing a 65-year-old woman and her doctor and are told she had several weeks of fever and rigors which she treated with NSAIDs. Two days before your interview she developed a diffuse headache and pain in her neck and was admitted. Her exam revealed mild meningismus and a "rash" on her palms. You are told a lumbar puncture showed a normal opening pressure, a protein of 110 mg/dl, a normal glucoose, and 60 neutrophils. No organisms were seen on Gram or India Ink staining and cultures are pending. A picture of her "rash" is shown below.
What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, would you recommend?
DIAGNOSIS: Bacterial endocarditis presenting with aseptic meningitis.
The hemorrhagic lesions on the palmar surface of this patient's hand are referred to as Janeway lesions, characteristically found in patients with bacterial endocarditis, usually due to Staphylococcus aureus - the causative organism in the presented case. Similar appearing lesions may occur in patients with vasculitis (e.g., granulomatous polyangiitis), purpura fulminans, purpuric forms of the antiphospholipid syndrome, gonococcemia and meningococcemia, but this is uncommon.
The incidence of neurological signs in patients with bacterial endocarditis is reported as high as 80% although most series show that 15 to 30% of patients will evidence neurological signs at some time during their illness. In the pre-antibiotic era, Streptococcus pneumoniae had the highest proclivity to involve the CNS. Today, Staphylococcus aureus and streptococci, which cause 90% of all cases of bacterial endocarditis, are most commonly implicated.
The neurological manifestations of endocarditis are miriad and include aseptic meningitis, fulminant bacterial meningitis, brain abscesses, strokes, transient ischemic episodes (TIAs), internuclear ophthalmoplegia, myelitis, mononeuritis, polyneuritis, optic neuritis, and unilateral blindness.
In addition to a thorough physical exam, the diagnosis is established by obtaining blood cultures and performing a lumbar puncture. Also indicated are a transthoracic echocardiogram and a CT or MRI angiogram.
To quote Sir William Osler: "Few diseases present greater difficulties in the way of diagnosis than malignant endocarditis, difficulties which, in many cases, are practically insurmountable..... The protean character of the malady, the latency of the cardiac symptoms, and the close simulation of other disorders combine to render the detection peculiarly difficult". Sir William Osler: Malignant endocarditis. Lancet 1: 415-418, 459-464, 505-508, 1885.