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Dr. H. is a very well-respected 60-year-old oncologist who’s been your patient for the past six years. Other than hyperactive airways disease as a child and mitral valve prolapse (diagnosed by the patient himself while still a medical student), he’s been very healthy. He smoked cigarettes, as most people including physicians did back in the ’70s, but only for a relatively short period of time. Every time he comes to your office for a consultation, which is rare, you’re intimidated because you wish you knew half the medicine that Dr. H. has forgotten. Dr. H. is also a stoic, who down-plays any and all physical symptoms.
One day, Dr. H. presents to your office with new-onset shortness of breath (SOB) on exertion, productive cough, and a low-grade fever of one week’s duration. He’s lost just over 2 kg and feels unwell, and for Dr. H. to say this, your spidey-sense starts tingling.
Dr. H. has started himself on clarithromycin but there’s been no clinical improvement after three days. On examination, the patient does indeed look toxic. There’s moderate air entry in all lung fields and scattered wheezing. You order a stat chest x-ray and some blood tests. The radiologist calls you a short while later to say that other than some mild pulmonary hyperinflation, the lungs are clear. The blood tests reveal a WBC count of 12 with a left shift and an elevated ESR of 54. All other tests are normal. What would you do?
My clinical impression was that the patient’s symptoms were due to a respiratory infection resistant to clarithromycin. Dr. H. agreed wholeheartedly and asked me to prescribe a different antibiotic so that he could be on his way. I changed his antibiotic to cefuroxime. Sputum and blood cultures were not ordered because of the prior use of antibiotics. Dr. H. was instructed to rest and call me with an update in a few days’ time.
Forty-eight hours later, the patient was brought to the Emergency Department by ambulance. He was diaphoretic, tachycardic, hypotensive and dehydrated, with rigours and a temperature of 39.5°C. Dr. H. was septic, but where was the source of the infection?
Dr. H. was found to have a grade IV/VI systolic murmur over the mitral area of his precordium. An echocardiogram was subsequently ordered showing vegetations on the mitral valve. Three weeks earlier, the patient had had a dental procedure but wasn’t in the habit of taking prophylactic antibiotics.
Dr. H. was diagnosed with subacute bacterial endocarditis (SBE) and started on three broad-spectrum antibiotics. Blood cultures grew Streptococcus viridans, sensitive to vancomycin. The patient remained on IV antibiotics for six weeks. Six months later, he underwent surgery to replace his badly damaged mitral valve. It’s now 10 years on and the patient is alive and well.
This case taught me several very important lessons:
- Do not let yourself be intimidated by your patient. Even doctors need help every once in awhile and they may lack the insight/judgement to make good clinical decisions. Treat them like everyone else!
- When it comes to bacterial endocarditis, have a high clinical index of suspicion. As far as I’m concerned, if a patient has a fever and an abnormal heart valve, he or she has SBE until proven otherwise!
Examine your patient thoroughly. Had I listened to Dr. H.’s heart carefully when he presented to my office, I would have noticed that his normally soft murmur had turned into a jet engine!
We'll send you $100 if we print your diagnostic challenge. Send case description (app. 450 words) with final diagnosis and outcome to: parkex@parkpub.com.
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