Clinical Communications: Adult| Volume 57, ISSUE 2, e45-e48, August 2019

Download started.


No Fever, No Murmur, No Problem? A Concealed Case of Infective Endocarditis



      Infective endocarditis is associated with significant morbidity and mortality, despite advances in diagnosis and treatment strategies. Injecting drug users are particularly at risk of endovascular infections, especially with multi-resistant and virulent microorganisms. Typically, patients with endocarditis present with constitutional symptoms, such as high fever and malaise combined with cardiorespiratory symptoms of valvular failure or emboli, such as septic pulmonary embolism.

      Case Report

      A 33-year-old female with a history of peptic ulcer disease presented to the emergency department with 3 days of increasing unilateral calf pain and swelling. There was no history of trauma or immobilization, no fever or clinical signs of sepsis or cardiopulmonary symptoms. A history of recent i.v. amphetamine injection in the forearm was elicited and empiric treatment for endovascular infection was commenced. Workup revealed methicillin-resistant Staphylococcus aureus mitral papillary endocarditis with gastrocnemius pyomyositis, multi-joint septic arthritis, and brain abscesses. After a 60-day inpatient stay, including intensive care admission for septic shock, the patient made a good recovery.

      Why Should an Emergency Physician Be Aware of This?

      The incidence of injecting drug use is increasing, and these patients are at risk of severe invasive infections with multi-resistant organisms. The emergency physician is most often responsible for the initial workup and treatment of patients with suspected infective endocarditis, with timely collection of blood cultures and appropriate antibiotics being essential interventions. This case highlights that even without fever, murmurs, or constitutional symptoms, severe multisystem infections from endocarditis can occur.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cahill T.J.
        • Baddour L.M.
        • Habib G.
        • et al.
        Challenges in infective endocarditis.
        J Am Coll Cardiol. 2017; 69: 325-344
        • Selton-Suty C.
        • Celard M.
        • Le Moing V.
        • et al.
        Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey.
        Clin Infect Dis. 2012; 54: 1230-1239
        • Delahaye F.
        • M’Hammedi A.
        • Guerpillon B.
        • et al.
        Systematic search for present and potential portals of entry for Infective Endocarditis.
        J Am Coll Cardiol. 2016; 67: 151-158
        • Cahill T.J.
        • Prendegast B.D.
        Infective endocarditis.
        Lancet. 2016; 387: 882-893
        • Wurcel A.G.
        • Anderson J.E.
        • Chui K.K.
        • et al.
        Increasing infectious endocarditis admissions among young people who inject drugs.
        Open Forum Infect Dis. 2016; 3: ofw157
        • Zibbell J.E.
        • Asher A.K.
        • Patel R.C.
        • et al.
        Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014.
        Am J Public Health. 2018; 108: 175-181
        • Mathew J.
        • Addai T.
        • Anand A.
        • Morrobel A.
        • Maheshwari P.
        • Freels S.
        Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis in intravenous drug users.
        Arch Intern Med. 1995; 155: 1641-1648
        • Badri M.
        • Sardar M.R.
        • Khitri A.
        • Gnall E.
        • Bradley J.
        Isolated posteromedial papillary muscle endocarditis.
        Eur Heart J. 2012; 13: 630