A 76 year old male with a past medical history of ischemic cardiomyopathy, DM2, HLD, HTN, COPD comes to clinic with a chief complaint of fevers. He denies any other symptoms On physical exam you hear a systolic ejection murmur grade I that has been present for years. He has a fever of 100.9 but all other labwork is negative. Blood cultures are positive for two out of two staphylococcus epidermidis. TEE is obtained which is negative for vegetations. You start him on linezolid for 2 weeks for bacteremia.
Three days later the patient calls and reports persistent fevers — he now is slightly short of breath more than usual but he also went to Denny’s every day this past weekend and Long John’s Texas Steakhouse. He is usually well controlled.
What do you do next?
- PET Scan
- MRI Chest
- Repeat TEE in 7-10 days
- Switch antibiotics, follow up in 2 weeks with repeat TEE
The answer is to repeat TEE in 7-10 days — though the sensitivity of TEE in detecting infective endocarditis is high (about 85-90%) there can still be false negatives. In cases of high clinical suspicion repeat TEE! This patient has new onset heart failure in the setting of persistent fevers — think infective endocarditis!