Just when I thought the sun would set behind the mountain, it rose and made yet another run across the valley. Time to step out of the twilight zone and get back on the donkey. Three hours away from the closest hospital and with an ultrasound probe in hand, I made another run for it.
A peculiar case this middle aged man was, bearing a captivating odor of fermented fish. Priorly morbidly obese with OSAS and CPAP night-time, he’d undergone laparoscopic gastric bypass a year previously, lost massive amounts of weight and was now carrying his skin like a half-empty sack of potatoes. His main complaint was tiredness and impaired life-lust. Family and friends had noticed his indifference. For the past months he’d slept most of the days, experienced muscle- and joint aches and some dizziness. I wasn’t immediately alarmed. Might as well have prescribed him antidepressants. I persisted and he answered question after question.
His apathy had almost rubbed off on me when I heard “visual disturbance, night-sweats” and snapped back. Two days ago he had suddenly gone blind on one eye. Five minutes later he regained vision only to be followed by another similar episode. This was a clear-cut case of…
Vitals were fine and he was afebrile. CRP 110. No cutaneous changes. But upon cardiac auscultation a pan-systolic and diastolic murmur was discovered! And wouldn’t you know, he’d had periodontitis for the past 20 years and root canal fixed three months ago. So what was in the Chinese fortune cookie?
Infective endocarditis. A dancing vegetation is present on the aortic valve non-coronary cusp and anterior mitral leaflet. There is an aortic regurgitation. And the crown jewel? Fistula between the aortic root and left atrium. Anatomically the aortic- and mitral annuli are fused at the fibrous trigone predisposing any vegetation to travel between one another sometimes producing an apparent abscess or fistula.
He was immediately admitted to the hospital. Antibiotics were prescribed and the patient planned for subacute surgery due to high risk of embolization. Blood cultures grew Streptococcus mitis, an inhabitant of the oral cavity. The cause of amaurosis fugax proved to be what we expected unfortunately. MR brain showed two small infarcts caused by septic embolization. Neurologic function remained intact however. And like any other success story, christmas didn’t arrive a day too early. The diseased valves were replaced by two intracardiac Philippe Pateks working around the clock keeping his life ticking.