Convexal Subarachnoid Hemorrhage Caused by Infective Endocarditis in a Patient with Advanced Human Immunodeficiency Virus (HIV): The Culprits and Bystanders

Abstract

BACKGROUND Convexal subarachnoid hemorrhage (cSAH), a rare form of non-aneurysmal subarachnoid hemorrhage, is confined to cerebral convexities without extension into basal cisterns or ventricles. Typical presentation includes thunderclap/progressive headache or transient focal neurological symptoms; rare manifestations include seizures, intractable vomiting, or altered mental status. Here, we report the first case of convexal subarachnoid hemorrhage and multifocal ischemic lesions caused by infective endocarditis (IE) in a treatment-naïve advanced HIV patient. CASE REPORT A 52-year-old HAART-naïve, HIV-positive, African American man presented with altered mental status, shortness of breath, nonproductive cough, and generalized weakness. His past medical history was significant for congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease (noncompliant with hemodialysis). Head computed tomography (CT) showed an isolated sulcal hemorrhage in the mid-left frontal lobe. Fluid-attenuated inversion recovery/gradient recalled echo sequences confirmed a hemorrhage in the left-mid-frontal sulcus, and diffusion-weighted imaging revealed multifocal bilateral ischemic lesions. Transesophageal echocardiography exhibited mitral valve vegetations. Multifocal ischemic lesions and cSAH caused by infectious endocarditis were confirmed. Initiation of intravenous vancomycin and piperacillin-tazobactam allowed the patient to have resolution of his altered mental status. A head CT 5 days later revealed the resolution of cSAH. CONCLUSIONS Infective endocarditis should be considered as an underlying etiology of cSAH, especially when present with multifocal ischemic lesions. Risk factors contributing to the development of cSAH in the IE patient population should be explored in future studies. HIV has not been previously reported in this subgroup and its prevalence should be considered. The prognosis for cSAH in relation to IE is generally favorable.

Figure 1.

Computed tomography of the head revealed hemorrhage in the mid-left frontal lobe convexity.

Figure 2.

Magnetic resonance imaging on T2 FLAIR (fluid-attenuated inversion recovery) showed a hemorrhage in the left-mid-frontal lobe gyrus.

Figure 3.

Magnetic resonance imaging on diffusion-weighted imaging showed multifocal bilateral punctate ischemic lesions in both anterior and posterior circulation.

Figure 4.

Magnetic resonance imaging on diffusion-weighted imaging showed multifocal bilateral punctate ischemic lesions in the cerebellum.

Figure 5.

Magnetic resonance imaging with gradient recall echo revealed a convexal hemorrhagic pattern in the mid-left frontal lobe without microhemorrhages and superficial siderosis.

Figure 6.

Magnetic resonance angiography did not show the presence of aneurysms or segmental vasoconstriction.

Figure 7.

Magnetic resonance angiography did not show the presence of aneurysms or segmental vasoconstriction.

Figure 8.

Computed tomography of the head performed 5 days after antibiotic treatment showed regression of the convexal subarachnoid hemorrhage.

Figure 9.

Flow chart depicting various types of subarachnoid hemorrhage. IE – infective endocarditis; HIV – human immunodeficiency virus; ADPKD – autosomal dominant polycystic kidney disease; CAA – cerebral amyloid angiopathy; RCVS – reversible cerebral vasoconstriction syndrome; AV – arteriovenous; AVM – arteriovenous malformation.

Figure 10.

Flow chart of cerebrovascular complications of HIV. HIV – human immunodeficiency virus; IE – infective endocarditis; NBTE – nonbacterial thrombotic endocarditis; DIC – disseminated intravascular coagulation; APS – antiphospholipid syndrome; TTP – thrombotic thrombocytopenic purpura.