A 49-year-old man presents to the physician with fever, confusion, and abdominal pain. His wife explains that for the past few days he has had fevers, night chills, and fatigue, but suddenly developed confusion this morning. His medical history is significant for hypertension and diabetes, for which he takes losartan, amlodipine, and metformin. He denies any tobacco, ethanol, or drug use. His vitals show a temperature of 38.4°C, a blood pressure of 142/90 mmHg, a heart rate of 96 beats per minute, and a respiratory rate of 16 breaths per minute. He has poor dentition, no jugular venous distention, and a normal pulmonary examination. There is a 3/6 holosystolic murmur heard over the apex. Blood cultures are drawn, and the patient is started on empiric antibiotics. A transthoracic echocardiogram shows a normal ejection fraction with no valvular lesions.
What is the most appropriate next step in management of this patient?a. Transesophageal echocardiogram
Transesophageal echocardiogram. The patient in this vignette meets one major and two minor of the modified Duke criteria for infective endocarditis (new regurgitant murmur, fever, and poor dentition and diabetes as predisposing conditions). Transesophageal echocardiography (TEE) has a much higher sensitivity to detect infective endocarditis than a transthoracic echocardiogram (TTE), and thus should be performed if the TTE is negative but there is still a high clinical suspicion for the diagnosis. (B) Surgery should be performed if there is serious valvular dysfunction (e.g., cardiogenic shock), recurrent emboli despite antibiotics, infection with specific organisms that are difficult to treat with antibiotics alone, and a few other indications that are not as high yield. (C) A CT scan of the chest would not be helpful to make a diagnosis at this point. (D) These tests are nonspecific markers of inflammation and would not be very useful in confirming or ruling out infective endocarditis. Elevation in these markers is a minor criterion in the modified Jones criteria for rheumatic fever. (E) IV steroids should not be given in this condition since there is active infection.