A 63-year-old woman with type 2 diabetes presented to her general practitioner with a 7 week history of chills, fever and fatigue. She has also experienced intermittent earache during this time, prompting her GP to diagnose otitis media and prescribe oral antibiotics.
Her symptoms persisted and she developed nausea and loss of appetite, accompanied by bilious vomiting, night sweats, weight loss and right sided hypochondrial pain. Two weeks before admission an outpatient ultrasound scan was arranged which was suggestive of recent cholecystitis and splenomegaly. The patient continued to feel unwell and her family brought her to the accident and emergency department at Chorley Hospital.
On examination she had a low grade temperature (37.8°C) and was haemodynamically stable. There was no clubbing or splinter haemorrhages, jugular venous pressure (JVP) was not elevated, heart sounds were normal, her chest was clear, and an abdominal examination revealed severe abdominal tenderness at the right hypochondrium. The rectal examination was unremarkable. A urine dipstick was positive for nitrites and leucocytes. There was no evidence of haematuria on urine microscopy.
Initial blood tests showed normal white blood cell count (WBC) at 5.5 (range 4–11) ×109/l, haemoglobin 15.2 (11.5–16.5) g/dl, and platelets 180 (range 140–440) ×109/l, but raised erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) at 105 (range 1–18) mm/h and 133 (0–5) mg/l, respectively. Raised α-glutamyl transferase (GGT) was noted at 95 (range 1–65) u/l. Urea and electrolytes (U&E) were normal. Chest radiography was unremarkable and the electrocardiogram (ECG) revealed normal sinus rhythm.
As the patient presented with an acute abdomen she was referred to the surgeons who made the diagnosis of acute cholecystitis and she was accordingly started on cefuroxime 750 mg three times a day. An abdominal CT confirmed the presence of an enlarged spleen and revealed a wedge shaped low density area of infarction in the right kidney. The gallbladder and biliary tree appeared normal ().
Right renal infarction evident on computed tomography scan.
The CT finding of right kidney infarction prompted the search for the potential source of the emboli. Therefore a transthoracic echocardiogram was arranged which showed moderate aortic regurgitation and good left ventricular function, but did not identify any vegetation. A previous echocardiogram, 4 years earlier, did not show any valvular abnormalities. At this stage blood culture grew Streptococcus oralis and a transoesophageal echocardiogram confirmed the presence of vegetations on both the non-coronary and left coronary aortic cusps.
On further questioning the patient denied any previous surgical procedures and she had no other gastrointestinal symptoms. Moreover, she did not have any history of congenital or acquired valvular heart disease.
The diagnosis was established as infective endocarditis. The patient was deemed suitable for medical treatment and improved following treatment with intravenous antibiotics (benzyl penicillin, 7.2 g daily in six divided doses, plus gentamicin, 1 mg/kg bodyweight every 8 h, modified according to renal function) for 6 weeks. She was then discharged home for outpatient follow-up.