A Barely Responsive Woman Dropped at the ED With a Note

Gregory Taylor, DO; Eric McDowell, DO


November 05, 2020

Treatment of infective endocarditis involves multiple modalities. Successful treatment involves appropriate antibiotic therapy and begins with initiating empirical therapy. Ultimately, the definitive antibiotic is based on the organism involved, the susceptibility, and whether the involved valve is prosthetic or native.[7]

Surgery is another treatment modality in selected patients, as the functional and structural integrity of the cardiac valves gets damaged. Such patients include those with endocarditis secondary to fungal infection; those with poor response to antibiotics; those with left-sided endocarditis caused by certain gram-negative bacteria; and those with valve dehiscence, perforation, or rupture.[8]

The overall prognosis of infective endocarditis depends on multiple factors. In one retrospective study involving 220 patients with right-sided endocarditis, the mortality rate was 6%; however, with a vegetation size > 2 cm, the mortality rate increased to 25%.[4] Another study showed that the presence of septic shock in the setting of staphylococcal bacteremia was associated with increased mortality rates of 38%-86%.[4]

The prognosis largely depends on the degree of complications that develop, host factors such as increased age and underlying comorbidities (eg, diabetes), and the development of congestive heart failure or large vessel embolization. If left untreated, infective endocarditis is usually fatal.[3]

The patient in this case was already in critical condition by the time she arrived at the ED. Chart examination revealed that the patient had been seen in the ED 1 week earlier for an accidental heroin overdose. Her chest radiograph revealed acute respiratory distress syndrome, and her laboratory and clinical examination findings indicated disseminated intravascular coagulation, all in the setting of septic shock that was probably due to rapidly progressive acute infective endocarditis. Her disease state was immediately recognized, and treatment was accordingly initiated. Early detection and treatment can be lifesaving; however, by the time this patient was dropped off at the front door of the ED, she was unable to be saved.


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