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1. INFECTIVE ENDOCARDITIS
COMPLICATED BY A HEART ABSCESS.
HOUSE M.D S05E23- UNDER MY SKIN

2. SYNOPSIS
• House and the team treat a ballerina whose lungs collapse during a
performance; House is desperate to find a cure for his insomnia.

3. CASE SUMMARY
• Penelope, a 36-year-old female dancer, presented to the emergency department with
progressively worsening chest pain, shortness of breath, and fatigue over several weeks. She
had a history of occasional palpitations but had not sought medical attention previously.
Initial examination revealed signs of heart failure and peripheral vascular compromise.
• Patient Penelope presented with a complex array of symptoms, including dyspnea, fever, and
severe chest pain, accompanied by cough and pleuritic chest pain. Initial investigations
revealed bilateral pulmonary infiltrates on chest X-ray, suggesting a possible infectious
etiology. However, further evaluation revealed an underlying cardiac issue, with evidence of
an abscess in her heart. Differential diagnoses considered included pneumonia, infective
endocarditis, and myocarditis. Treatment initially involved empirical antibiotics for suspected
pneumonia, but upon discovering the cardiac abscess, surgical intervention was required.
Penelope underwent a successful abscess removal procedure, but subsequent complications
arose, including peripheral ischemia due to vasospasm induced by high-dose dopamine
administration. Despite challenges, comprehensive management involving surgical
intervention and meticulous medical support ultimately led to Penelope's successful
recovery.

4. DIAGNOSIS
• Penelope's diagnosis was ultimately determined to be infective endocarditis
complicated by a heart abscess. This diagnosis was supported by several key factors:
persistent symptoms despite antibiotic therapy, evidence of systemic emboli with
pulmonary involvement, and the identification of a cardiac abscess on imaging studies.
The presence of fever, dyspnea, pleuritic chest pain, and bilateral pulmonary infiltrates
raised suspicion for infective endocarditis, which was further corroborated by
echocardiography revealing vegetations on the heart valves. The development of
septic emboli resulting in peripheral ischemia and the need for amputation
underscored the severity and systemic nature of the infection. Management involved a
multidisciplinary approach, including aggressive antibiotic therapy targeting the
causative microorganism, surgical intervention to drain the abscess, and supportive
care to address complications such as peripheral ischemia. Close monitoring and
follow-up were essential to ensure resolution of the infection and prevent further
complications.

5. TREATMENT
• In the case of Penelope's infective endocarditis complicated by a heart
abscess, pharmacological treatment played a crucial role in managing her
condition. Antibiotics, such as vancomycin and gentamicin, were likely
initiated to target the bacterial infection responsible for the endocarditis
and prevent its progression. These antibiotics are commonly used for
infective endocarditis and have broad-spectrum coverage against various
pathogens commonly implicated in such infections. However, adverse
effects such as nephrotoxicity and ototoxicity are known risks associated
with gentamicin use, necessitating careful monitoring of renal function
and auditory status throughout the course of treatment. Additionally, the
interaction between vancomycin and gentamicin should be considered,
as concurrent use may potentiate nephrotoxicity.

6. TREATMENT
• In managing Penelope's hemodynamic instability and sepsis, dopamine was administered to
augment her blood pressure and improve perfusion to vital organs. Dopamine is a vasopressor
agent commonly used in septic shock to increase systemic vascular resistance and cardiac output.
However, dopamine can also have adverse effects such as tachycardia, arrhythmias, and tissue
necrosis if extravasation occurs. Close hemodynamic monitoring is essential during dopamine
infusion to titrate the dose and minimize the risk of adverse effects.
• Metroprolol, a beta-blocker, may have been used to control Penelope's heart rate and reduce
myocardial oxygen demand, particularly if she presented with tachycardia or atrial fibrillation.
However, the use of beta-blockers in infective endocarditis is controversial due to concerns about
potential hemodynamic compromise and masking signs of sepsis. Furthermore, beta-blockers can
interact with other medications, such as dopamine, leading to additive effects on blood pressure
and heart rate. Therefore, cautious dose adjustment and vigilant monitoring of clinical response
and adverse effects are imperative when using metroprolol in this context.
• Overall, the pharmacological management of Penelope's case required a careful balance between
addressing the infectious process, stabilizing her hemodynamics, and minimizing the risk of adverse
drug reactions and interactions.

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