A 45-year-old woman is brought to the emergency department due to confusion. According to her husband, the patient has had fatigue, poor appetite, and fleeting joint pain for 2 weeks. She has a history of rheumatoid arthritis, which is treated with a tumor necrosis factor-alpha inhibitor. Temperature is 38.9 C (102 F), blood pressure is 142/76 mm Hg, and pulse is 101/min and regular. Two small subconjunctival hemorrhages are noted in the right eye; there is no papilledema. A 2/6 holosystolic murmur is present at the apex. The lungs are clear. There is no swelling or redness of the joints. The patient is poorly cooperative with neurologic examination but moves all extremities. MRI of the head is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 45-year-old woman is brought to the emergency department due to confusion.  According to her husband, the patient has had fatigue, poor appetite, and fleeting joint pain for 2 weeks.  She has a history of rheumatoid arthritis, which is treated with a tumor necrosis factor-alpha inhibitor.  Temperature is 38.9 C (102 F), blood pressure is 142/76 mm Hg, and pulse is 101/min and regular.  Two small subconjunctival hemorrhages are noted in the right eye; there is no papilledema.  A 2/6 holosystolic murmur is present at the apex.  The lungs are clear.  There is no swelling or redness of the joints.  The patient is poorly cooperative with neurologic examination but moves all extremities.  MRI of the head is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d48c_15a1_bc81_a7035dd8c47e_MD0003_00 This patient with confusion and fever has multiloculated, rim-enhancing fluid lesions in the temporal lobe, indicating likely brain abscess. Brain abscess usually occurs due to direct spread from adjacent infection (eg, sinusitis) or hematogenous spread from distant infection. In this case, the presence of subacute nonspecific symptoms, subconjunctival hemorrhage (petechiae), and signs of mitral valve insufficiency (holosystolic murmur at cardiac apex) raises suspicion for left-sided infective endocarditis (IE) with septic emboli to the eye and brain. rim-enhancing fluid lesions Because patients with IE often have several weeks of mild, nonspecific symptoms (eg, mild fever, arthralgia, myalgia, malaise), many cases present with complications due to cardiac injury (eg, heart failure from valve dysfunction) or septic emboli. Valvular vegetations from left-sided IE often travel to the brain, leading to ischemic stroke, meningitis, or abscess; septic emboli to other structures (eg, kidney, spleen, spinal cord, joints, conjunctiva/retina, skin) also frequently occur. Work-up begins with 3 sets of blood cultures from 3 different venipuncture sites and transthoracic echocardiography (TTE) to evaluate for valvular vegetations or abscess. When TTE is negative and the diagnosis of IE uncertain, a transesophageal echocardiogram can provide better visual assessment (sensitivity >90%). (Choice A) Antineutrophil cytoplasmic antibodies are seen with granulomatosis with polyangiitis and microscopic polyangiitis, which can cause multisystemic symptoms (eg, fleeting joint pains, fatigue) and ophthalmologic and neurologic manifestations (including, in rare cases, CNS lesions due to granuloma). However, they usually cause upper or lower airway and renal disease, and peripheral neuropathies are more common. The combination of holosystolic murmur, subconjunctival hemorrhages, and brain abscess makes IE much more likely. (Choices C and F) HIV increases the risk of brain abscess and opportunistic brain infection (eg, toxoplasmic encephalitis). Although toxoplasmic encephalitis often causes confusion, MRI usually shows multiple, bilateral ring-enhancing lesions. Given this patient's heart murmur and subconjunctival hemorrhage, septic emboli from IE are more likely. (Choice D) Focal brain lesions are usually a contraindication to lumbar puncture due to the risk of herniation. A microbial diagnosis would likely be established by blood culture and/or culture of an aspiration sample. (Choice E) Stereotactic brain biopsy can diagnose malignant brain lesions when no other biopsy site is available. Because this patient's cardiac murmur and conjunctival hemorrhage raise suspicion for IE, noninvasive testing (eg, TTE, blood cultures) would likely be done before considering more invasive testing (eg, brain biopsy). However, this patient may ultimately require stereotactic needle aspiration of the brain abscess given its size. Educational objective: Infective endocarditis often causes several weeks of nonspecific symptoms, complications related to septic emboli (eg, brain abscess), and new heart murmur. Initial workup includes 3 sets of blood cultures and echocardiography. References: Septic cerebral embolisation in fulminant mitral valve infective endocarditis. (http://www.ncbi.nlm.nih.gov/pubmed/26120312) Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24215865)

A 45-Year-Old Woman Is Brought to the Emergency Department Due