Haemophilus parainfluenzae endocarditis with multiple cerebral emboli in a pregnant woman with coronavirus

De Castro, Alicia; Abu-Hishmeh, Mohammad; El Husseini, Ibrahim; Paul, Lisa

Imaging also plays a vital role in diagnosing IE. One of its major diagnostic criteria hinges on echocardiographic evidence of an oscillating intracardiac mass or vegetation, an annular abscess, prosthetic valve partial dehiscence, or new valvular regurgitation [9] . Here, the initial TTE demonstrated no vegetation. A recent meta-analysis on the use of echocardiography in detecting vegetations notes that TTE has a sensitivity of 61% and specificity of 94%, and as such can fail to show many vegetations that are otherwise identifiable on TEE [10] . Of interest, it has been noted that vegetations are detected in a lower percentage in HACEK endocarditis (71%) in comparison to non-HACEK endocarditis (83%), though there was no difference in the rates of mitral and aortic valve vegetations between the two populations [8] . Because there was a high clinical suspicion for IE given the patient's positive blood cultures and septic intracranial emboli, a TEE was recommended. Given the patient's occupation as a singer and her fear of damaging her vocal cords, she refused TEE and opted for a repeat TTE. A repeat TTE performed 5 days after the initial TTE showed a vegetation that was greater than 1 cm in dimension. This interval increase in size of the vegetation to the point of detectability despite antimicrobial therapy is critical, as it has been shown that this carries an increased risk of complications and the need for surgery [11] .