INFECTIVE ENDOCARDITIS WITH DISSEMINATED SEPTIC EMBOLI PRESENTING AS ST-ELEVATION MYOCARDIAL INFARCTION

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis with disseminated septic emboli can manifest with wide range of clinical presentations. The most frequently identified electrocardiographic finding is conduction abnormality present in 10% of these patients. ST-segment changes constitute a rare electrocardiographic finding in patients with infective endocarditis. We present a case of infective endocarditis with disseminated septic emboli phenomenon presenting with electrocardiographic findings consistent with ST-elevation myocardial infarction (STEMI). CASE PRESENTATION: 38-year-old female presented with a five-day history of worsening chest pain, high-grade fever, bilateral lower extremity weakness, and back pain. Past medical history is significant for intravenous drug use, Methicillin-Resistant Staphylococcus Aureus (MRSA) infective endocarditis involving mitral valve and untreated Hepatitis C. On presentation, patient was afebrile and tachycardic. Laboratory analysis was remarkable for leukocytosis, lactic acidosis, elevated troponins and a positive opiate and cocaine urine drug screen. On electrocardiograph, ST-elevation was noted in the lateral and inferior leads. Patient underwent emergent coronary angiography that revealed non-obstructive coronary artery disease. Echocardiogram revealed a normal left ventricular ejection fraction and small mitral valve vegetation without any significant valvulopathy. There was no pericardial effusion or thickening. Blood cultures grew MRSA. CT scan chest was significant for bilateral cavitary and noncavitary nodules consistent with septic emboli. CT abdomen revealed splenomegaly with multiple splenic and bilateral renal cortical infarcts. CT brain revealed multiple septic emboli at the grey-white matter interface with microhemorrhages involving cerebrum and cerebellum. Patient was initiated on broad-spectrum antibiotics later adjusted to cultures. Subsequently, patient was intubated for acute respiratory failure with shock requiring pressor support. Her condition continued to deteriorate and developed multi-organ system failure. Patient was transitioned to comfort measures only and she expired. DISCUSSION: Myocardial infarction may be seen in 3-10% of patients with infective endocarditis associated with septic emboli phenomenon. When present, the initial presentation of infective endocarditis is usually chest pain. Cardiac catheterization shows non-obstructive disease in 95% of cases. Septic emboli to coronary vessels is the most likely mechanism of STEMI in this subset of patients. The 30-day mortality in these patients is 40%, much higher than 3% seen in unclassified STEMI patients. CONCLUSIONS: STEMI is a rare presentation of infective endocarditis with the most likely mechanism being septic emboli to coronary vessels and overall much higher mortality as compared to unclassified STEMI. REFERENCE #1: Nazir, S., et al., ST-Elevation Myocardial Infarction Associated With Infective Endocarditis. Am J Cardiol, 2019. 123(8): p. 1239-1243. REFERENCE #2: Ryu, H.M., et al., Presence of conduction abnormalities as a predictor of clinical outcomes in patients with infective endocarditis. Heart Vessels, 2011. 26(3): p. 298-305. DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Christopher Wood, source=Web Response