Cutaneous symptoms uncover unintentionally obscured disease
figure 1: Conjunctival hemorrhage was among the cutaneous signs discovered.
Mr. B, a 33-year-old registered nurse working in the intensive care unit of a medical center in Washington State, presented to the otolaryngology (ENT) clinic after being referred from the emergency department (ED) for recurrent sinusitis. The patient related a four-month history of intermittent retro-orbital headaches, low-grade fevers, chills, fatigue, malaise, and dyspnea when exercising. A number of clinician-colleagues had informally evaluated Mr. B and treated him for presumed sinusitis with multiple courses of antibiotics, including augmentin, clindamycin, and azithromycin. Mr. B's symptoms would temporarily resolve while taking the antibiotics but recur shortly after completion.
1. History and examination
Six weeks prior to presentation to the ENT clinic, Mr. B was evaluated by a cardiology consultant for complaints of heart palpitations following exercise. He was found to have sustained sinus tachycardia. Echocardiography demonstrated a competent bicuspid but otherwise normal aortic valve. No further diagnosis was made nor treatment given.
Two days before presentation, the patient was evaluated in the ED for complaints of headache, fever, and palpitations. He had a temperature of 102°F (38.9°C) and sinus tachycardia with a rate of 105. He was diagnosed with an upper respiratory infection and started on a course of doxycycline. The ED physician referred Mr. B to the medical center's ENT clinic for further evaluation of recurrent sinus infections.
Mr. B's medical history was significant for herpes zoster, sickle cell trait, and a congenital bicuspid aortic valve. The patient's only previous operations were a tonsillectomy and adenoidectomy. The only medications he took were the recently prescribed doxycycline and occasional ibuprofen. Mr. B described a history of a rash reaction to sulfa medications. Family history was unremarkable. The patient was athletic, did not use tobacco or drugs, and was a very light drinker.
Physical exam at the ENT clinic revealed temperature 97.8° F (36.6° C), pulse 53, BP 122/58 mm Hg, and respiration rate 16 with oxygen saturation 98%. Mr. B appeared generally well and fit. Examination of the head, neck, and sinuses was unremarkable except conjunctival and palatal lesions (Figure 1 and 2). Cardiovascular auscultation revealed a 2/6 diastolic murmur loudest at the left upper sternal border. Strong radial pulses were detected. Examination of lungs was normal, as was that of the abdomen. An extremity examination revealed additional lesions (Figure 3, 4, and 5). There was no peripheral edema.
Complete blood count results were as follows: Leukocytes 8,500; hemoglobin 12.6 g/dL, hematocrit 38.1%, and platelets 236,000. Urinalysis showed some RBCs but was otherwise normal.
The patient's constitutional symptoms could be caused by many systemic processes, including vasculidities, rickettsial infections, viral or bacterial infections, and malignancies. Mr. B's cutaneous stigmata indicate a diagnosis of subacute bacterial endocarditis.
Mr. B's history of a deranged aortic valve, constitutional symptoms that would temporarily remit during antibiotic treatment, dermatologic micro-embolic and vasculitic phenomena, mild anemia, and microhematuria supported a diagnosis of bacterial endocarditis. The cutaneous signs in this patient included mucosal and conjunctival petechiae (Figure 1 and 2), subungual splinter hemorrhages (Figure 3), Janeway lesions (nontender erythematous macules usually found on the palms and soles), and Osler's nodes (Figure 4) (painful and tender areas of induration often located on the pads of the fingers and toes).1
Blood cultures grew Streptococcus viridans. Transesophageal echocardiography showed a bicuspid aortic valve with vegetations and moderate-to-severe aortic regurgitation.
The possible diagnoses listed above can manifest with fevers and other constitutional symptoms, but their dermatologic manifestations are different from those of endocarditis.
Bicuspid aortic valve is the most common congenital heart valve abnormality, affecting 1%-2% of people.2 It is often a clinically insignificant condition but can lead to aortic stenosis, aortic regurgitation, and endocarditis. Endocarditis prophylaxis is recommended for patients with aortic stenosis who are undergoing invasive or dental procedures.3
Mr. B was admitted for treatment with IV gentamycin and ceftriaxone as well as lisinopril and aspirin. After completion of adequate antibiotic treatment as demonstrated by negative blood cultures and echocardiographic evidence of resolved valvular vegetations, he underwent an aortic root and valve replacement to correct extensive valvular destruction.
This case demonstrates the potential for liability and patient harm inherent in the practice of curbside consultations. Had Mr. B been formally evaluated soon after the onset of his symptoms, he may have been diagnosed much sooner and avoided the eventual valvular destruction and subsequent valvular transplant surgery. The well-intentioned informal evaluations and antibiotic prescriptions by several of the patient's clinician-colleagues obscured the diagnosis and enabled the disease to progress.
LTC Rice is a family physician at Madigan Army Medical Center in Fort Lewis, Wash. He would like to thank Col. Gary Clark, MC, USA and Capt. John Holman, MC, USN, for their assistance. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army at large.
1. Crawford MH, Durack DT. Clinical presentation of infective endocarditis. Cardiol Clin. 2003;21:159-166.
2. Ratib O, Perloff JK, Child JS. Images in cardiovascular medicine. Bicuspid aortic valve aneurysm. Circulation. 2004;109:671.
3. Fedak PW, Verma S, David TE, et al. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation. 2002;106:900-904.