Listen to Your Heart, or at Least Theirs: Maintaining a High Index of Suspicion for Infective Endocarditis

After an endothelial injury, a fibrin and platelet cap forms. This cap is typically sterile but in times of infection can become colonized by microbes leading to a vegetation. When this occurs on the endothelium of the heart, it is termed infective endocarditis (IE). IE is a difficult diagnosis to make in the ED. The symptoms are vague. Classic exam findings are often absent, murmur auscultation can be challenging and there is not a single diagnostic test. A delayed or missed diagnosis can be fatal; therefore, it is essential that ED physicians maintain a high index of suspicion in high risk patients (IVDA, valve disease, congenital heart disease, prosthetic valves and other cardiac devices) presenting with fever and/or general viral-like symptoms. Despite significant advances in medicine, the mortality and incidence of IE have not decreased over the last 30 years.¹-² This maybe in part due to diagnosing cases late in the disease course and IVDA associated with the ongoing opioid epidemic. Some of the sequalae include heart failure, septic emboli, intracerebral hemorrhage and coagulation cascade disturbances. Here we discuss a case of severe infective endocarditis and the unfortunate complications and outcome.