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Answers on p245.
A 59 year old insulin dependent diabetic male presented with an eight week history of lower thoracic back pain and a two to three week history of progressive exertional dyspnoea, limiting his exercise tolerance to around 100 yards, associated with mild ankle oedema. He did not complain of cough or chest pain. He had been discharged from another hospital four weeks earlier after a prolonged admission with pneumonia and renal failure.
There was no other past medical history of note. In particular, there was no history of cardiac disease. He was taking insulin and enalapril.
Box 1: Blood results (normal range in parentheses)
Sodium, potassium normal
Urea = 11.4 mmol/l (2.5–6.5)
Creatinine = 158 μmol/l (40–110)
Glucose = 9.1 mmol/l (3–6.7)
Albumin = 30 g/l (30–52)
Globulins = 54 g/l (18–35)
Calcium, other liver function tests and thyroid function tests normal
Haemoglobin = 91 g/l (130–180)
Mean corpuscular volume = 83 fl (80–100)
White blood cells = 19.4 109/l (4–11)
Neutrophils = 16.2 109/l (2–7.5)
Clotting screen normal
Erythrocyte sedimentation rate = 144 mm/hour
Arterial blood gases (room air):
pH = 7.49 (7.35–7.45)
Carbon dioxide pressure = 3.3 kPa (4.7–6.0)
Oxygen pressure = 8.9 kPa (>10.6)
Oxygen saturation = 94%
Bicarbonate = 19 mmol/l (24–30)
On examination, he was comfortable at rest though appeared chronically unwell. Temperature was 38.5°C. there were no cutaneous stigmata of endocarditis. Cardiovascular examination revealed a resting tachycardia of 120 beats/min, a gallop rhythm, systolic and diastolic murmur over the pulmonary area, and mild bilateral ankle oedema. Chest auscultation revealed bilateral basal rales. Abdominal and neurological examinations were unremarkable. There was tenderness over the lower thoracic spine.
Blood results are shown in box 1.
Chest radiography showed cardiomegaly with patchy shadowing at both bases (fig 1). The electrocardiogram showed sinus tachycardia with right bundle branch block.
Given the history of back pain with hyperglobulinaemia and very high erythrocyte sedimentation rate, multiple myeloma was considered likely complicated either by a community acquired bibasal pneumonia or multiple pulmonary emboli. Two sets of blood cultures were taken and the patient started on subcutaneous low molecular weight heparin and antibiotics while awaiting urgent echocardiography and VQ scanning.
The next day, Staphylococcus aureus was cultured from all four blood culture bottles. The appearance of a magnetic resonance imaging scan of the thoracic spine and transthoracic echocardiogram are shown in figs 2 and3.
(1) What is the unifying diagnosis?
- How does right sided endocarditis usually present?
- What risk factors are recognised for right sided endocarditis in non-intravenous drug users?
- What is the likelihood of endocarditis in cases of S aureusbacteraemia?
- What is the relationship between back pain and endocarditis?