A fatal case of infective endocarditis complicated by acute COVID-19 pneumonia
In November 2020, a 74-year-old man with no co-morbidities presented to the emergency department of his local hospital with a 3-day history of diarrhoea and vomiting. On examination, he was agitated with a Glasgow Coma Scale (GCS) score of 12/15 (E4, V3 and M5). He had a pansystolic murmur that was heard loudest at the apex, which radiated to the left axilla. He had a number of physical signs suggestive of IE, which are shown in and . He also had evidence of impaired oral hygiene, which is shown in . His inflammatory markers were elevated. His peripheral blood cultures were taken, and he was started on intravenous ceftriaxone immediately afterwards. His blood culture grew Staphylococcus aureus. A routine SARS-CoV-2 nasopharyngeal swab taken on admission was negative. A transthoracic echocardiogram showed severe mitral regurgitation () as well as vegetations on both mitral and aortic valves (). Consequently, the patient satisfied two major criteria (new valvular regurgitation and the presence of vegetations) as well as three minor criteria (multiple Osler nodes, a Janeway lesion and a single positive blood culture) of the modified Duke’s criteria for IE []. Hence, definite IE was confirmed.\nshows the trend in his white cell count and estimated glomerular filtration rate (eGFR) over Days 1–9. During this time, his GCS ranged between 11/15 (E4, V2 and M5) and 15/15. An abdominal ultrasound on Day 5 showed no evidence of renal obstruction, hence, his renal failure was attributed to worsening sepsis. By Day 8, he had become anuric and he was treated with haemodialysis on Days 8 and 9.\nOn Day 10, he was transferred to a tertiary hospital for mitral valve replacement. He was admitted to the intensive care unit for continuous venovenous haemofiltration. However, a routine admission nasopharyngeal swab for SARS-CoV-2 on Day 11 was positive, thus delaying his surgery. We believe this infection may have occurred either during transit or during the final few days of the patient’s admission at his local hospital. On admission to the tertiary hospital, he underwent serial nasopharyngeal swabs for SARS-CoV-2 at twice weekly intervals. A plan was made to operate as soon as he tested negative, or as soon as we could be satisfied that his COVID-19 pneumonia incubation period had elapsed.\nHowever, on Day 24, he developed nausea and vomiting. Computerised Tomography (CT) imaging of his chest showed peripheral ground glass change with bilateral pleural effusions in keeping with COVID-19 pneumonia (). He was started on supplementary oxygen, oral dexamethasone and intravenous remdesivir. This was in accordance with local guidelines for the management of COVID-19 pneumonia at the time. He initially maintained an oxygen saturation >92% without the need for invasive ventilation. However, he died on Day 31 from acute respiratory distress syndrome (ARDS) secondary to COVID-19 pneumonia.