This case involves a previously healthy thirty-year-old female patient who presented to a medical clinic with complaints of a three day history of nausea, vomiting, fever, chills, myalgia, headaches and other flu-like symptoms. The clinic performed a chest x-ray and nasal swab and the results negative; no other blood work was performed. The patient was sent home and continued to experience symptoms with increased lethargy, photophobia and poor oral intake. She was taken to the hospital by EMS and admitted to telemetry for tachycardia and positive orthostatic symptoms. The patient was being treated for rhabdomyolysis and acute renal failure with intravenous fluids. There was no mention of abnormal lab reports of an elevated WBC count or suspicions of infection on a differential diagnosis during this workup. Infectious Disease was finally consulted (nearly 72 hours later) and the service recommended broad spectrum antibiotic coverage immediately as it had been delayed for a significant period after the patient was admitted. The patient decompensated over the next 48 hours during her hospital stay before passing away. During the course of this 48 hour period the treating physician recorded in the patient’s notes: All measured parameters continue to improve. WBC normalized and temp curve moving down [note – max temp on the 1st was 101.7]. Last TEE clearly shows increasing size of mass on ventricular side. Pathophysiology is unclear – whether represents ongoing bacterial activity or edema/blood insudation into disrupted annular area where inflammatory activity could be expected. MRI (of heart) not good quality to judge extent of ventricular myocardial abnormality, however one of series suggested the location of the phlegmon to be adjacent to the proximal circumflex/LMCA a location difficult to access surgically and repair safely. Best option is watchful waiting, intensive antibiosis and vigorous nutritional support as surgical evacuation of ventricular abscess in this region carries substantial risk. If insufficiency develops risk/benefit ratio might move toward operation. “…recent indirect signs infection coming under control”. The autopsy report revealed that the patient had a large mitral valve vegetation and exhibited multiple sequelae of bacterial endocarditis that caused an eventual intracerebral hemorrhage which was the proximate cause of death.
Question(s) For Expert Witness
Have you ever encountered a patient with this condition? Can you determine if this patient would have fared better (to a reasonable degree of medical certainty) if earlier intervention occurred?
Expert Witness Response E-004465
I have encountered many patients with this condition. I practice in an area where IV drug use is common and, unfortunately, so is infective endocarditis.
Missing a large vegetation on the mitral valve likely means that something very obvious on the physical exam was either not performed or overlooked, which would lead one to make the correct diagnosis. Delaying antibiotics certainly did not help out, but likely occurred because the correct diagnosis had not been made. Although possible, it seems unusual that this sick patient with infective endocarditis had normal lab values and normal blood cultures.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
