A 35-year-old man comes to the physician with a 2-week history of low-grade fever and progressive weakness. He has a long history of "heart murmur." He does not use illicit drugs. Examination shows splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur. His erythrocyte sedimentation rate is 96 mm/h. Urinalysis shows microscopic hematuria and 1+ proteinuria. Which of the following valvular dysfunctions is most likely to be detected in this patient?

Question

A 35-year-old man comes to the physician with a 2-week history of low-grade fever and progressive weakness.  He has a long history of "heart murmur."  He does not use illicit drugs.  Examination shows splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur.  His erythrocyte sedimentation rate is 96 mm/h.  Urinalysis shows microscopic hematuria and 1+ proteinuria.  Which of the following valvular dysfunctions is most likely to be detected in this patient?

Quizplus · Accepted Answer

11ec25c8_d44d_ada4_bc81_81a8568027b9_MD0003_00 This patient's presentation is consistent with infective endocarditis (IE). Patients with IE typically complain of fever, chills, and generalized malaise. Although these symptoms are rather nonspecific, other clues such as prior history of an underlying heart condition (eg, heart murmur), indwelling structures (eg, intravascular catheters), or history of intravenous drug use should prompt further investigation for bacteremia associated with endocarditis. About 75% of patients with IE have previously damaged heart valves, with mitral valvular disease being the most common. Patients with mitral valve prolapse and associated regurgitation have a 5-8 times higher risk of IE than those with a normal valve. (Choice A) The aortic valve is the second most common cardiac valve involved in IE, usually in patients with prior history of congenital bicuspid aortic valve with associated aortic stenosis. Aortic regurgitation is seen in IE but less frequently. (Choice C) Mitral stenosis, in patients with or without rheumatic heart disease, is an uncommon underlying valvular abnormality associated with IE. (Choice D) Pulmonic stenosis is typically not associated with IE. (Choice E) Tricuspid regurgitation is more commonly associated with IE in intravenous illicit drug users. Educational objective: Mitral valve disease, usually mitral valve prolapse with coexisting mitral regurgitation, is the most common valvular abnormality detected in patients with infective endocarditis. References: Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. (http://www.ncbi.nlm.nih.gov/pubmed/19273776)

A 35-Year-Old Man Comes to the Physician with a 2-Week