Initial investigations revealed haemoglobin 9.5 g/dl, mean corpuscular volume 78 fl, white blood cell count 9.4×109/l, platelets 173×109/l, negative urine dipstick and normal renal function. C reactive protein (CRP) was raised to 76 mg/l (normal <10).
Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) were positive (1:320), and anti-PR3 were detected at a titre of 24 IU/ml (normal <6). Cryoglobulins were also positive, but antinuclear antibodies and antibodies to extractable nuclear antigens (Ro, La, Sm, U1RNP, RNP70, CENP, Jo-1, Scl-70) were negative. Tests for hepatitis B antigen, hepatitis C antibodies and HIV antibodies were negative. The patient also underwent skin biopsy, which did not show any features of cryoglobulinaemia or leukocytoclastic vasculitis.
MRI of the thoraco-lumbar spine, requested to investigate back pain, revealed abnormal fluid collection in the L2/3, L3/4, L5/S1 discs with inflammatory changes in the adjacent end plates and further mild changes at T8/9 level suggestive of multifocal infective spondylodiscitis ().
Figure 1 MRI of the spine showing abnormal fluid collection in the L2/3, L3/4, L5/S1 discs with inflammatory changes in the adjacent end plates with further mild changes at T8/9 level, in keeping with multifocal early infective spondylodiscitis in the lower thoracic (more ...)
During hospitalisation, the patient developed pyrexia and three sets of blood cultures grew Enterococcus faecalis. Further clinical examination demonstrated splinter haemorrhages in three finger nails. Subsequently, transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) were performed. Both revealed large tricuspid valve vegetations with severe tricuspid regurgitation associated with destruction of the septal leaflet (). TOE was performed to provide a more detailed anatomical assessment because despite appropriate antimicrobial therapy, the patient initially did not respond well to treatment and suffered from persistent fever and raised inflammatory markers. In addition, he had severe tricuspid regurgitation on TTE and TOE was needed for surgical planning.
Transoesophageal echocardiogram showing: (A, B) tricuspid valve vegetation (solid arrows), (C) damaged septal leaflet (broken arrow) and (D) severe tricuspid regurgitation.
There was no obvious source of endogenous bacteraemia but in view of positive cultures for E faecalis and microcytic anaemia, the patient was investigated for colonic malignancy. Contrast CT scan of abdomen and pelvis, tumour markers including carcino-embryonic antigen, total hCG, α-fetoprotein, and carbohydrate antigen 19.9 (CA 19.9) and colonoscopy were normal.