ANSWER 93
This 79-year-old man has the clinical features of aortic stenosis and regurgitation. The
murmurs are of mixed aortic valve disease and the ECG shows left ventricular hypertrophy
(sum of negative deflection in V1 and positive deflection in V5 or V2 and V6 greater than
35 mm), suggesting that there has been significant pressure overload from aortic stenosis.
The findings of mixed aortic valve disease, microscopic haematuria, malaise and fever
(probable with the night sweats) make infective endocarditisa likely diagnosis. This would
fit with the haematological picture showing a normocytic anaemia, a raised neutrophil
count and a high ESR. In the elderly, infective endocarditis may be an insidious illness and
should be considered in any patient who has murmurs and fever or any other change in the
cardiac signs or symptoms. The other classical findings of splenomegaly, splinter haemor-
rhages, clubbing, Osler’s nodes, Janeway lesions and Roth’s spots are often absent.
Precipitating events such as dental treatment or other sources of bacteraemia may not be
evident in the history.
It is difficult to tie all the features into any other single diagnosis. The signs are of aortic
valve disease. When there is a fever or other evidence of infection in the presence of valve
disease, infective endocarditis must always be considered although in practice other unre-
lated infections are more common. Other infections such as tuberculosis or abscess are
possible or an underlying lymphoma or other malignancy.
The most important investigations would be:
- blood cultures performed before any antibiotics are given. In this case three blood cul-
tures grew Streptococcus viridans - echocardiogram which showed a thickened bicuspid aortic valve, a common congeni-
tal abnormality predisposing to significant functional valve disturbance in middle and
old age. Vegetations can be detected on a transthoracic echocardiogram if they are
prominent, but transoesophageal echocardiogram is more sensitive in detecting vege-
tations on the valves.
Treatment with intravenous benzylpenicillin and gentamicin for 2 weeks, followed by oral
amoxicillin resulted in resolution of the fever with no haemodynamic deterioration or
change in the murmurs of mixed aortic valve disease. A microbiologist should be con-
sulted about appropriate antibiotics and duration.
After treatment of the endocarditis, the symptoms of pain and tiredness on exertion would
need to be considered to see if valve surgery was indicated. Prior to this it would be rou-
tine to look at the coronary arteries by angiography to see if simultaneous coronary artery
surgery was needed.
- Symptoms on exertion in aortic valve disease are a sign that valve surgery needs to be
considered. - In infective endocarditis, it is unusual to have many of the classical physical signs. In the
elderly, it may present with non-specific malaise.