A 34-year-old Woman

With Fever, Tachycardia, Vomiting,

and Hemiparesis

N U R S E P R A C T I T I O N E R S F O R U M

Author: Jennifer Ezell, MSN, RNC, ACNP, CEN, Franklin, Tenn

Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN

Jennifer Ezell, Middle TN ENA Chapter, is Acute Care NursePractitioner, Centennial Medical Center, and Assistant Professor,Vanderbilt University School of Nursing, Nashville, Tenn.

For reprints, write: Jennifer Ezell, MSN, RNC, ACNP, CEN;E-mail: Jennifer.l.ezell@mcmail.vanderbilt.edu.

J Emerg Nurs 2004;30:275-7.

0099-1767/$30.00

Copyright n 2004 by the Emergency Nurses Association.

doi:10.1016/j.jen.2004.03.005

June 2004 30:3

A34-year-old woman who presented to triage

reported having fever, nausea, and vomiting

intermittently for the previous 2 weeks. She

had experienced generalized malaise, weakness, and ex-

treme fatigue beginning the day that she arrived at the

emergency department. She had been hospitalized a week

earlier for dehydration, but her fever had continued after

discharge. She denied having a headache. Her medical

history was negative, and she denied taking any medica-

tions. Her vital signs were as follows: blood pressure, 118/

70 mm Hg; heart rate, 154 beats per minute; respiratory

rate, 20 breaths per minute; and temperature, 40jC

(104jF). Her oxygen saturation on room air was 98%.

She was not orthostatic.

During her physical examination, the patient did not

use her left arm, and the strength in her left upper and

lower extremities was significantly decreased. However,

she denied extremity weakness or loss of function. She

had no other abnormal neurologic signs or symptoms,

and the findings from the remainder of her examination

were unremarkable.

Initially, we administered a 1 L intravenous bolus of

0.9% normal saline solution, 1 g of acetaminophen, and

800 mg of ibuprofen, orally, for her fever, along with

12.5 mg of intravenous promethazine for her nausea. Blood

was drawn for a complete blood cell count, basic metabolic

panel, and coagulation studies, which revealed a hemoglo-

bin level of 8 g/dL (normal range, 13.8 to 17.2 g/dL) and a

hematocrit level of 25% (normal range, 41% to 50%). The

remainder of the laboratory results were within normal

ranges, as were the results from the urine drug screen. The

EKG revealed a sinus tachycardia.

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NURSE PRACTITIONERS FORUM/Eze l l

Because of the patient’s left-sided hemiparesis, a

computed tomography scan of her head was ordered,

which revealed a moderate right-sided infarct. Upon

receiving the computed tomography results, the nurse

practitioner strongly suspected that the patient had bacte-

rial endocarditis. We treated her empirically with intrave-

nous doses of vancomycin, gentamicin, and ceftriaxone

and admitted her to the hospital in stable condition.

During her hospital stay, a 2D echocardiogram was

performed, which revealed a large vegetation on the

anterior mitral valve leaflet. The patient received cardiol-

ogy and infectious disease consults. Twenty-four hour

growth on blood cultures collected in the emergency

department revealed gram-positive cocci, consistent with

systemic infection from bacterial endocarditis.

Discussion

Patients frequently come to the emergency department

with fever, generalized malaise, and fatigue. Infective

bacterial endocarditis is an uncommon1 but potentially

life-threatening condition that should be considered as a

differential diagnosis for these patients, especially those

with significant risk factors. Our patient’s condition was

more difficult to diagnose because she exhibited none of

the many risk factors that are often associated with

endocarditis. Patients with endocarditis are more typically

male, with such possible risk factors for infection as a

history of intravenous drug use, immunosuppression (eg,

HIV), recent surgery, indwelling catheters or prosthetic

heart valves, and long-term hemodialysis. Congenital heart

defects also can play a role.

Microbial invasion of the endothelial layer of the

heart causes the infection, with lesions (vegetation) com-

monly composed of platelets, fibrin, microorganisms, and

inflammatory cells. The signs and symptoms of the

condition are systemic, even though the infection origi-

nates in the heart. Fever that typically lasts several weeks

is the most common symptom. Other signs and symp-

toms include headache, fatigue, exertional dyspnea,

cough, anorexia, weight loss, night sweats, back pain,

malaise, pallor, petechiae, and splenomegaly. Some

patients have Osler’s nodes (tender, subcutaneous nodules)

on the fingers and toes and Janeway’s lesions (nontender

276

erythematous, hemorrhagic, or pustular lesions) on the

palmar or plantar surfaces. If the valves on the left side of

the heart are involved, the patient may have a murmur. Our

patient exhibited fever, fatigue, malaise, and a cardiac

murmur but had none of the other classic signs and

symptoms of bacterial endocarditis.

JOUR

[Because of the high rate of neurologiccomplications,] endocarditis must beconsidered in patients presenting with afever and strokelike symptoms.

Laboratory findings typically are nonspecific and may

include anemia (as with our patient), leukocyctosis, abnor-

mal urinalysis (microscopic hematuria and proteinuria),

and elevated sedimentation rate and C-reactive protein

level. Although our patient did not have EKG changes,

nonspecific findings such as new bundle branch blocks

and atrioventricular or fascicular blocks are possible in

patients with endocarditis, but only when the patient has

perivalvular invasion. The presence of cardiac valve

vegetation detected on the echocardiograph is diagnostic

for endocarditis.

Our patient’s cerebral infarct was the result of an

emboli from her cardiac vegetation. In addition to the

brain, emboli most commonly travel to the spleen, kidney,

liver, and iliac or mesenteric arteries. Congestive heart

failure and myocardial infarcts from emboli in the coro-

nary arteries are rare1 but are among the more serious

potential cardiac complications.

Anticoagulation therapy has not beenshown to prevent embolic events andmay serve only to increase the riskof intracerebral hemorrhage.

Neurologic complications, however, are more com-

mon and develop in 20% to 40% of all patients diagnosed

with infective endocarditis.1 Because of this high correla-

tion, endocarditis must be considered in patients presenting

with a fever and strokelike symptoms. Overall mortality

rates remain as high as 20% to 25%.1,2

NAL OF EMERGENCY NURSING 30:3 June 2004

NURSE PRACTITIONERS FORUM/Eze l l

Therapy for patients with negative blood cultures and

native valves (ie, those with no mechanical replacements)

includes penicillin, ampicillin, ceftriaxone, and/or vanco-

mycin, with the possible addition of an aminoglycoside.1,3

Anticoagulation therapy has not been shown to prevent

embolic events and may serve only to increase the risk of

intracerebral hemorrhage.1 Surgical intervention may be

indicated if the patient exhibits heart failure, uncontrolled

infection, significant valve dysfunction, artificial valve

infection, or abscess formation.4

Once the fever has resolved and blood cultures are

negative, the patient often completes treatment on an

outpatient basis (usually 6 weeks long).3,4 Our patient

received aggressive intravenous fluid hydration and

antibiotics and was discharged home after less than a

week with minimal and resolving left-sided weakness.

REFERENCES

1. Mylonakis E, Calderwood SB. Medical progress: infective endo-carditis in adults. N Engl J Med 2001;345:1318-30.

2. Netzer RO, Zollinger E, Seiler C, Cerny A. Infective endocar-ditis: clinical spectrum, presentation and outcome. Heart 2000;84:25-30.

3. Eykyn SJ. Endocarditis: basics. Heart 2001;86:476-80.

4. Cabell CH, Abrutyn E, Karchmer AW. Bacterial endocarditis:the disease, treatment and prevention. Circulation 2003;107:185-7.

Submissions to this column are welcomed and encouraged. Sub-missions may be sent to:

Gail Pisarcik Lenehan, RN, EdD, FAAN,c/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002

800 900-9659, ext 4044 . awbkelly@comcast.net

June 2004 30:3 JOURNAL OF EMERGENCY NURSING 277