Acute limb ischemia: A rare and devastating complication of infective endocarditis

Abstract

Introduction Infective endocarditis (IE) is defined as a microbial infection of the endocardial surface of the heart which commonly involves one or more valves, mural endocardium damaged by aberrant jets of blood or foreign bodies, or intracardiac devices.1-2 The annual incidence of IE among Filipinos in the largest tertiary referral center in the country was reported to be 10 cases per 10,000 person days, with an equal male to female distribution and a mean age of 30 years.3 Complications may occur at the involved valve or at extra-cardiac locations that can result in serious morbidity and mortality if left untreated or inappropriately treated.1-2 Systemic embolization, a feared complication of IE, occurs in 22% to 50% of patients with IE which may occur Case Series Philippine Journal of Internal Medicine prior to or during the initiation of antibiotics.4 This significantly contributes to increased morbidity and mortality.1-5 In contrast to embolic events to the brain, lungs and spleen which have comprehensively been discussed in literature, acute limb ischemia (ALI) due to septic embolization is un-commonly reported.1, 4 To date, there have been no reported cases of ALI as a complication of IE among Filipinos in our institution and to the best of our knowledge, this may be the first local report to be published. This paper aims to increase awareness of this uncommon and devastating complication of IE which warrants aggressive intervention upon recognition in the hopes of decreasing morbidity and mortality. Case Presentation Case 1 A 27-year-old male with rheumatic heart disease had intermittent fever and myalgia for six months. He developed dyspnea for one month which progressively worsened prompting admission. He denied illegal drug use. On admission, he was febrile (38°C). Blood pressure was 90/60 mmHg, heart rate was 98 bpm and respiratory rate The PHILIPPINE JOURNAL OF INTERNAL MEDICINE is a peer reviewed journal and a copyrighted publication of the Philippine College of Physicians Volume 57 Number 1 April-June, 2019 111 Introduction: In contrast to embolic events to the brain, lungs and spleen which have been comprehensively discussed in literature, acute limb ischemia (ALI) due to septic embolism (SE) from infective endocarditis (IE) are uncommonly reported. There have been no reported cases of ALI as a complication of IE among Filipinos to date making this case report the first in our country. Case Presentation: We report two cases of community-acquired native valve endocarditis caused by streptococcus spp. and enterococcus faecalis. Both patients had large and mobile vegetations in the mitral valve and aortic valve respectively on transthoracic echocardiography. The first one developed ALI (IIa) on the R leg after the initiation of antibiotics. The second case presented with ALI (IIa) on the R leg on admission. They were given the appropriate antibiotics and received systemic anticoagulation with heparin. The first case underwent successful emergency embolectomy on the R leg but developed new-onset ALI on the L leg and refused further intervention. Embolectomy was also recommended on the second patient who also re-fused any intervention. Despite maximal medical management, both patients subsequently expired. Conclusion: Infective endocarditis (IE) patients are at risk to develop SE before or during the initiation of appropriate antibiotics. ALI is a life threatening extra cardiac complication of IE. Early recognition and prompt aggressive management are therefore imperative.