Complex Infective Endocarditis: Uncommon Presentations and Their Multisystem Complications - A Case Series

Abstract

Infective endocarditis (IE) is a potentially life-threatening condition characterized by infection of the heart valves or endocardial surface, leading to significant morbidity and mortality. This case series explores four unusual presentations of IE, highlighting the diverse etiologies and complex multisystem complications that can arise from this condition. The clinical manifestations of IE can vary widely, ranging from systemic embolization to acute heart failure, reflecting the varied spectrum of pathogens involved and the patient's underlying health status. Key risk factors include preexisting valvular heart disease, intracardiac devices, intravenous drug use, and immunocompromised states. Prompt and accurate diagnosis is crucial for effective management, with echocardiography serving as the gold standard imaging modality and playing a key role as the first-line tool. Both transthoracic and transesophageal echocardiography are invaluable in identifying vegetations, evaluating valve function, and detecting potential complications such as abscesses, valve perforation, and intracardiac fistulas. The high sensitivity and specificity of echocardiography allow for early detection, even in cases with subtle or atypical presentations, ensuring that timely medical or surgical interventions are initiated. In addition, echocardiography is essential in monitoring treatment response, guiding clinical decisions, and determining the need for surgical valve replacement when severe damage or persistent infection is evident. This series emphasizes the importance of a multidisciplinary approach to treatment, which may include both medical and surgical interventions, tailored to the patient's specific clinical scenario. A heightened awareness of atypical presentations and the need for timely intervention are critical for improving patient outcomes, particularly in high-risk populations.

Keywords: Case series; echocardiography; embolization; infective endocarditis; multisystem complications.

Figure 1

Transthoracic (a) and transesophageal (b) echocardiography showing a mobile vegetation on the aortic valve

Figure 2

Coronary angiogram showing the embolic occlusion of the left anterior descending

Figure 3

Transesophageal echocardiography showing vegetations on both, 11 and mitral valves

Figure 4

Magnetic resonance imaging of the brain showing subacute ischemia

Figure 5

Transesophageal echocardiography showing a large vegetation on the pacemaker lead

Figure 6

Embolism in the segmental branch for the middle-basal region of the right lower lobe (further downstream) with iodine map obtained from dual-energy computed tomography acquisition

Figure 7

Transesophageal echocardiography showing a large vegetation on tricuspid valve