Infective Endocarditis

A 7-year-old boy presented with a history of fever for 10 days with occasional cough. The fever was moderate grade with a maximum temperature of 102.4 F. He had been hospitalized 1 week before the onset of fever with a diagnosis of severe dengue fever. He was in the pediatric intensive care unit for 3 days and had recovered fully at the time of discharge. There was no other significant past medical or surgical history. In the first week of fever, he was initially treated with oral amoxicillin for a presumed respiratory infection. When fever persisted, he was hospitalized elsewhere, and his investigations revealed a neutrophilic leukocytosis and an erythrocyte sedimentation rate of 44 mm in the first hour. He was started on IV ceftriaxone to which fever responded initially. His cultures were sterile and other investigations were normal. As no conclusive diagnosis could be made and his fever returned after the initial response, he was referred to our hospital. On examination, he was febrile and ill-appearing. His heart rate was 115/min and respiratory rate was 30/min. There was no respiratory distress. His general physical examination and systemic examination were normal. The child was hospitalized for further evaluation. His initial investigations revealed a normocytic normochromic anemia, neutrophilic leukocytosis, and elevated serum C-reactive protein levels. The chest X-ray showed focal pulmonary infiltrates. The possibility of a bacterial infection was considered. Blood cultures were sent, and the child was started on IV ceftriaxone. The blood culture grew methicillin-resistant Staphylococcus aureus (MRSA), and the antibiotic was changed to IV vancomycin. As fever continued unabated, blood culture was repeated after 48 h which again grew MRSA. The child was re-evaluated for metastatic infections. Echocardiography (ECHO) revealed a vegetation of 1.1 cm × 0.9 cm attached to the anterior leaflet of the tricuspid valve (TV) and low-grade tricuspid regurgitation. A diagnosis of infective endocarditis was made. The child was continued on IV vancomycin. He became afebrile on day 7. The antibiotics were continued for a total of 6 weeks. Repeat ECHO showed a significant decrease in the size of vegetation. The patient was discharged in a stable condition with no fever and a weight gain of 2 kg.