By: Joseph Benedict, M.D.

35 year old female with a history of of IV drug use (last use 3 days prior) complicated by HCV, 2 prior overdoses presents from detox center with 2 days of worsening abdominal pain, malaise, myalgias, painful rash and 1 day of worsening confusion, vision change.  Denies fever, chest pain, nausea, vomiting.  History limited by confusion and severity of condition.

VS: HR 98    BP 98/55    T 99.2F     RR 20    SpO2 98% on RA

Physical exam
GEN: Appearing unwell and in moderate distress. Intermittently moaning.
HEENT: Subconjunctival petechia and scleral hemorrhage
CV: harsh holosystolic murmur heard best at apex
PULM: Tachypneic but clear to auscultation bilaterally
ABD: Non-distended. Soft. Mild diffuse tenderness, worse in low midline.
MSK: Non-painful/normal ROM throughout.
SKIN: Petechial rash throughout.  Tender hand/feet rash. (see images below)

EKG and CXR were obtained

POCUS was performed showing the following:

Diagnosis: Infective endocarditis with vegetation on posterior mitral valve and evidence of wide-spread septic emboli.

Case resolution: Labs including three blood cultures were drawn prior to the patient receiving broad spectrum antibiotics and IV fluids. CT brain, chest, abdomen, pelvis demonstrated widespread embolic disease.  She was admitted to the ICU.

For brief review of diagnosis and management of infective endocarditis, see the following resources: 

Infective Endocarditis Review on Life in The Fast Lane

MD-Calc Duke Criteria for Infective Endocarditis

Resident Author: Joseph Benedict, MD
Faculty Review: Meera Muruganandan, MD