CASE LEARNING OBJECTIVES
Recognize the signs and symptoms of infective endocarditis (IE)
Understand the pertinent laboratory and imaging tests that should be performed to assist in the diagnosis, treatment, and monitoring of IE
Identify the initial and long-term goals of therapy for IE
Develop an appropriate treatment regimen, including length of treatment, for this particular patient on the basis of organism characteristics and treatment guidelines for IE
Determine appropriate monitoring parameters to evaluate response of the IE therapy
Understand which patients need prophylactic therapy and what therapy is appropriate for the prevention of IE
"I've had a fever off and on for the past 2 weeks. My leg hurts and is swollen. I just don't feel very good, my body aches and I am tired all the time."
History of Present Illness
LB is a 38-year-old Caucasian man who presents to the emergency department with complaints of intermittent high fever (103–104°F [39.4–40.0°C]), chills, malaise, myalgias, and arthralgias for the past 2 weeks, as well as lower right leg erythema and edema for the past 3–4 weeks. He has been treated numerous times for recurrent cellulitis over the area of a previous gunshot wound (GSW) with evidence of injection drug use noted in the same area. Over the past year, he has been admitted to the hospital three times with right leg cellulitis (last admission was 2 months ago). He has been treated in the past with cefazolin, vancomycin, and trimethoprim/sulfamethoxazole. The area of cellulitis extends down from the groin to midthigh. The patient reports that the last intravenous drug abuse (IVDA) was 4 weeks ago. He has chronic leg pain due to the GSW and takes tramadol, Lortab, and Percocet for pain control. He states that the pain has increased over the past month, and he has been taking more medication to control the pain.
GSW 8 years ago (right upper leg/groin area)
Recurrent cellulitis over the past 3–4 years (CA-MRSA + in the past)
Father and mother are both alive. Father is 55 years and has a history of COPD and dyslipidemia. Mother is 52 years and has no significant past medical history. He has 2 younger siblings: one sister aged 24 years and 1 brother aged 21 years; both are healthy.
He was married but divorced after being incarcerated for selling illicit drugs. He has 1 child, aged 14 years, but does not have any contact. He was in prison for 6 years, but was released about 1½ years ago. He lives with his girlfriend at the present time and is ...