A 59-year-old man presented to a community Emergency Department with a one-month history of subjective fevers and dyspnea. Due to COVID-19 restrictions, he had only consulted a physician via telephone, during which he was prescribed two courses of antibiotics for presumed pneumonia. Despite treatment, his symptoms persisted. He denied any recent travel, intravenous drug use, or significant past medical history, but reported active tobacco use.
Initial assessment:
- Temperature: 38.4°C
- Heart Rate: 86 bpm
- Blood Pressure: 142/78 mmHg
- Respiratory Rate: 16 breaths/minute
- SpO2: 98% on room air
Physical examination:
The patient appeared comfortable and non-dyspneic at rest. A holosystolic murmur loudest at the apex was noted on chest auscultation. The patient denied any prior history of a murmur. Initial blood work, urinalysis, and a chest X-ray were largely unremarkable, with the exception of an elevated white blood cell count.
Point-of-care ultrasound (PoCUS):
Given the murmur and concern for endocarditis, point-of-care ultrasound (PoCUS) was employed. Cardiac imaging was performed using the parasternal long axis (PSLA), parasternal short axis (PSSA), and apical four-chamber (A4C) views.
For more on mastering your cardiac PoCUS skills, click here.
Key findings included:
- No pericardial effusion, right heart strain, or contractility abnormalities.
- A mobile mass on the anterior mitral valve leaflet.
- Severe mitral regurgitation with aliasing on colour Doppler.
A focused lung PoCUS revealed no B-lines or pleural effusions:
PSLA
PSSA
A4C
A4C CD
Clinical decision-making:
The PoCUS findings raised a strong suspicion for native valve infective endocarditis with severe mitral regurgitation, warranting both targeted antibiotics and surgical intervention. With limited cardiology resources over the weekend at our community hospital, the case was discussed with our local Cardiologists. The patient received appropriate antibiotics and was admitted under the medicine service.
More on the ultrasound diagnosis of endocarditis here.
Subsequent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) confirmed the PoCUS findings. The patient was transferred to a tertiary cardiac surgery centre for definitive management within 48 hours of his ED presentation.
Discussion:
This case underscores the critical role of PoCUS in facilitating timely diagnosis and management, especially in settings with constrained resources. During the early COVID-19 pandemic, healthcare access limitations were a stark reminder of systemic challenges. While long-term solutions require systemic reforms, equipping healthcare providers with advanced PoCUS skills can improve patient outcomes by enabling efficient decision-making at the bedside.
Join the Ottawa PoCUS Symposium – Mastering the Pulse on February 14, 2025!
Celebrate Valentine’s Day 2025 by advancing your cardiac PoCUS skills! Learn from top University of Ottawa educators and experts at the Ottawa PoCUS Symposium on February 14, 2025.
Early Bird Deadline: December 1, 2024.
Key Learning Points
- Consider Endocarditis in the febrile patient without a source or a prolonged fever.
- Mitral Regurgitation can be detected with POCUS by looking at valve coaptation and applying colour Doppler.
- In our ongoing state of health resource limitations POCUS may help to triage the need for inpatient vs. outpatient workup.
- High quality learning available at the Ottawa POCUS Symposium – Mastering the Pulse, February 14, 2025
