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A Febrile, Hypotensive Patient With Bilateral Lung Crackles

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 61-year-old man with a history of hypertension presented to the emergency department with a 1-day history of fever, dyspnea, and generalized weakness. His vital signs were temperature, 38.4°C (101.1°F); blood pressure, 94/40 mm Hg; heart rate, 116/min; and respiratory rate, 26/min. He was diaphoretic and had poor dentition. A soft S1 was present on cardiac examination, and crackles were auscultated in basilar lung fields bilaterally. Three sets of blood cultures from different sites were obtained. Cardiology, cardiac surgery, and infectious disease physicians were consulted. A bedside transthoracic echocardiogram was performed, the patient was transferred to the intensive care unit, and a transesophageal echocardiogram was obtained (Figure 1).

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Severe acute aortic regurgitation secondary to infective endocarditis

B. Perform emergency surgery for aortic valve repair

The key to the correct diagnosis is the presence of fever and hemodynamic instability with physical examination findings consistent with pulmonary edema and aortic regurgitation. Imaging demonstrated acute regurgitation, consistent with acute aortic valve insufficiency. Emergency intervention is indicated because of his symptoms of heart failure.

Acute aortic regurgitation causes a sudden reflux of blood from the aorta into the left ventricle during diastole. Decreased cardiac output results in compensatory tachycardia and increased myocardial oxygen demand. The incompetent aortic valve reduces coronary arterial flow, impairing myocardial perfusion. Increased left atrial pressure causes flash pulmonary edema, leading to cardiopulmonary failure.1 Symptoms of acute aortic regurgitation include diaphoresis, fatigue, and dyspnea. Examination may reveal a widened pulse pressure from decreased diastolic pressure or a soft S1 murmur caused by increased left ventricular diastolic pressure and early mitral valve closure. A faint systolic murmur may be present if aortic regurgitation is severe. Bilateral crackles from pulmonary edema may be auscultated.1

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Article Information

Corresponding Author: Nicholas Oh, MD, University of California, Los Angeles, 10833 Le Conte Ave, 72-227 CHS, Los Angeles, CA 90095 (noh@mednet.ucla.edu).

Published Online: May 20, 2019. doi:10.1001/jama.2019.6546

Conflict of Interest Disclosures: None reported.

Additional Information: We thank the patient’s sister for providing permission to share the patient’s information.

References
1.
Wang  A, Gaca  JG, Chu  VH.  Management considerations in infective endocarditis.  JAMA. 2018;320(1):72-83. doi:10.1001/jama.2018.7596PubMedGoogle ScholarCrossref
2.
Roberts  WC, Ko  JM, Moore  TR, Jones  WH  III.  Causes of pure aortic regurgitation in patients having isolated aortic valve replacement at a single US tertiary hospital (1993 to 2005).  Circulation. 2006;114(5):422-429. doi:10.1161/CIRCULATIONAHA.106.622761PubMedGoogle ScholarCrossref
3.
Baddour  LM, Wilson  WR, Bayer  AS,  et al.  Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association.  Circulation. 2015;132(15):1435-1486. doi:10.1161/CIR.0000000000000296PubMedGoogle ScholarCrossref
4.
Li  JS, Sexton  DJ, Mick  N,  et al.  Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.  Clin Infect Dis. 2000;30(4):633-638. doi:10.1086/313753PubMedGoogle ScholarCrossref
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le Polain de Waroux  JB, Pouleur  AC, Goffinet  C,  et al.  Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography.  Circulation. 2007;116(11)(suppl):I264-I269.PubMedGoogle Scholar
6.
Lalani  T, Cabell  CH, Benjamin  DK,  et al; International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS) Investigators.  Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis.  Circulation. 2010;121(8):1005-1013. doi:10.1161/CIRCULATIONAHA.109.864488PubMedGoogle ScholarCrossref
7.
Pettersson  GB, Coselli  JS, Pettersson  GB,  et al; AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs; Writing Committee.  2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary.  J Thorac Cardiovasc Surg. 2017;153(6):1241-1258. doi:10.1016/j.jtcvs.2016.09.093PubMedGoogle ScholarCrossref
8.
Nguyen  DT, Delahaye  F, Obadia  JF,  et al; AEPEI Study Group.  Aortic valve replacement for active infective endocarditis.  Eur J Cardiothorac Surg. 2010;37(5):1025-1032. doi:10.1016/j.ejcts.2009.11.035PubMedGoogle ScholarCrossref
9.
Goldstone  AB, Chiu  P, Baiocchi  M,  et al.  Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.  N Engl J Med. 2017;377(19):1847-1857. doi:10.1056/NEJMoa1613792PubMedGoogle ScholarCrossref
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