Abdominal angina as the presenting symptom in

1
Abdominal angina as the presenting
symptom in
bacterial endocarditis.
Daniel Suders DO, Tom Waltz DO, Adel Frenn MD,
Demetrio Agcaoili MD Ohio Valley Medical Center

• Case
• This is a 61 year old male who presented with 50
  pound weight loss over five months, abdominal
  pain, poor oral intake, general fatigue and
  malaise. Abdominal pain was described as
  intermittent cramping pain, it was worse with
  eating, which lead to his poor appetite and
  weight loss.
• Prior work-up for this complaint by
  Gastroenterology included EGD and HIDA scan.
  These tests showed Barretts esophagus and
  biliary dyskinesia. He was sent to a surgeon and
  underwent cholecystectomy. Pathology showed
  chronic cholecystitis, but after recovery from
  surgery, his symptoms were unchanged. Upon
  questioning, he did relate some dental work
  followed by a sinus infection prior to the start
  of his abdominal symptoms.
• Past medical history included CAD, atrial
  fibrillation, HTN, and hyperlipidemia.

• Case
• The patient was admitted and found to suffer from
  acute renal failure, acute anemia, and hemoccult
  positive stools. A colonoscopy was performed and
  showed evidence of ischemic colitis. Blood
  cultures returned positive for alpha
  streptococcus. Echocardiogram showed an aortic
  valve vegetation, and TEE confirmed an
  intravalvular abscess between the aortic and
  mitral valves. The size of the vegetation was
  estimated at 3x3 cm. He was treated with IV
  Rocephin and Vancomycin. The cardiac surgeons at
  our center were uncomfortable with the complexity
  of the surgery he would need, and recommended
  transfer to a tertiary center. He was
  transferred to Cleveland Clinic, where he
  underwent debridement and replacement of the
  aortic valve, mitral valve and intervalvular
  fibrosa. This surgery in itself is relatively
  rare, and has only been performed since 1997. In
  the end, he did well, and was able to be
  discharged to home.

Conclusion Endocarditis is a relatively uncommon
cause of febrile illness, but blood cultures
should be sampled in any febrile illness,
particularly once it becomes protracted.
Abdominal pain, mesenteric ischemia, and renal
failure are all possible presenting symptoms of
embolic endocarditis, though less common than
neurologic changes or pulmonary emboli. A good,
thoughtful, osteopathic internist, following the
osteopathic tenets, should consider the patient
as a whole in a case like this to make the
appropriate diagnosis. We often fall into the
trap of containing the work up to one organ or
system, which did occur in this case for some
time. For example, this patient had even
underwent a cholecystectomy for these abdominal
symptoms, before the true etiology was
discovered. This also illustrates the role of
the internist as the informational hub, which
is essential to the coordination of patient
care. This was an interesting and challenging
case that illustrates the importance of a
thorough history and physical and the need to
consider the patient as a whole.

• Of note, no one on the case appreciated a heart
  murmur, despite the large size of the vegetation.
  
• Some of the more commonly seen embolic phenomena
  in endocarditis include neurological symptoms,
  secondary to cerebral septic emboli and pulmonary
  infarcts secondary to septic emboli to the lungs.
  This patient did not show signs of either, but
  was found to have ischemic colitis, suspected to
  be secondary to septic emboli to the mesenteric
  arteries. While this has been documented in the
  literature, it is very rare. We believe that the
  intermittent abdominal pain that went on for
  months was likely caused by intermittent embolic
  occlusion of the mesenteric arterial system,
  causing abdominal angina.
• The overall vagueness of his symptoms was a
  challenge for everyone on the case. During his
  long outpatient workup, a blood culture had never
  been checked, despite continued intermittent
  fevers. Even during the admission where the
  diagnosis was made, it took a few days to
  discover the true source of his symptoms. During
  which some of the sub-specialists were chasing
  down other causes of his symptoms.

Discussion While the symptoms the patient was
experiencing are common to subacute endocarditis,
this diagnosis was not considered for many
months. He exhibited several of the Dukes minor
criteria, including fever, renal failure
suspected to be secondary to glomerulonephritis,
and evidence of major arterial emboli. Of
course, the diagnosis of endocarditis was
definitive after the positive blood cultures and
obvious vegetation on TEE.
Literature Cited 1. Misawa, Sakano, et al.
Septic embolic occlusion of SMA induced by mitral
valve endocarditis. Annals Thoracic
Cardiovascular Surgery 2011 Vol. 17, No. 4
415-417 2. Double valve replacement and
reconstruction of the intravalvular fibrous body
in patients with active infective endocarditis.
European Journal Cardiothoracic Surgery 2013. 3.
Guler, Sokmen, et al. Infective endocarditis
developing serious multiple complications. BMJ
Case Reports 2013 doi 10.1136/bcr-2012-00
8097. 4. Kim, Park, et al. Long-Term Results of
Aortomitral Fibrous Body Reconstruction With
Double-Valve Replacement. Ann Thorac Surg
201395 635-641
ACOI Annual Convention and Scientific Sessions
2013

• Poster Presentation by Daniel J Suders DO