A 71-year-old patient with a history of prostatic cancer, recently underwent CABG and mitral valve replacement and during cardiac rehabilitation (CR) was diagnosed with a cryptogenic stroke while on treatment with oral anticoagulant and antiaggregants. It is worth mentioning that during hospitalization he suffered several feverish episodes without major organ involvement with the only exception of the one related to the chest scar infection. He was admitted to CR department with high fever (38.5 C) and hemocultures were positive for Staphylococcus epidermidis which was also isolated from the chest scar. The transthoracic echocardiogram executed at the admission did not show any pathological alteration. After 5 days of antibiotic therapy and optimized medical therapy, he had an ischemic stroke. NIHSS score was initially 10. Acute presentation of ischemic stroke was peculiar: he had left hemiparesis with Babinski sign, but a concomitant Broca's aphasia, thus suggesting multiple areas of cerebral ischemia. He was evaluated with a basal computerized tomography (CT) scan which didn’t show any sign of ischemic stroke and NIHSS score completely reversed after 30 minutes to 0: this was more suggestive for a transient ischemic attack rather than ischemic stroke but despite the negative CT scan, the subsequent cerebral magnetic resonance imaging showed ischemic signs localized in different vascular territories. Supra-aortic vessels were normal. Therefore, we performed a transesophageal echocardiography (TEE) which showed a peculiar vegetation over the mitral valve, presenting more as a filament rather than typical vegetation. Despite the absence of fever, negative PCR, negative procalcitonine and white blood cells within the normal limits, we performed hemocultures and Staphylococcus haemolyticus was isolated. Antibiotic therapy was immediately started; however, after three weeks of appropriate therapy the TEE exam showed an evolution of the valve’s lesion which required surgical revision.
Conclusion
This case highlights how ischemic stroke related to multiple ischemic foci may be the only sign of an underlying endocarditis that caused septic embolization. Indeed, the patient was completely asymptomatic, did not have fever, inflammatory markers were negative and only clinical investigations to understand the nature of his stroke allowed us to make the diagnosis of endocarditis.