A 19-year-old male presented with recurrent fever and weight loss for 10 months. He has a history of bicuspid aortic valve with severe aortic regurgitation. On examination, he appeared ill with clubbing and multiple pigmented lesions. Tests found anemia, elevated inflammatory markers, and Enterococcus species in blood cultures. Echocardiography showed vegetation on the aortic valve with worsening of valve abnormalities and cardiac function. The final diagnosis was infective endocarditis in the setting of a bicuspid aortic valve with severe aortic regurgitation.

1. A 19-Year-Old Male
presented with
recurrent fever
and
weight loss

2. Particulars of the patient
• Name : Md. Tamim
• Age: 19 years
• Sex: Male
• Address: Kurigram
• Marital status: Unmarried
• Occupation: Garment’s worker
• Religion: Islam
• Date of admission: 19.10.2023

3. Chief Complaints
• Recurrent episode of fever for 10 months
• Weight loss for same duration

4. History of present illness
According to the statement of the patient he
was reasonably well 10 months back. Then he
developed-

5. History of present illness
• Recurrent episodes of fever for 10 months
 Latest episode for last 15 days
 Sudden onset
 High grade
 Remittent
 Highest recorded temperature 105 degree Fahrenheit
 Associated with chills and rigor
 Subsided by taking anti pyretic medication with sweating
 Not associated with any evening rise of temperature or night
sweat
 Associated with burning sensation during micturition and
frequency of micturition
 Previous five episodes were similar which were subsided by
consulting local physician and taking antibiotic the name of
which he can’t mention

6. History of present illness
• Weight loss
 Unintentional
 10 kg over 10 month
 Associated with loss of appetite

7. History of present illness
• On query he gives history of palpitation
 Spontaneous
 Persistent
 Not relieved by any specific measures
 Associated with occasional breathlessness and
chest pain

8. History of present illness
• He gives no history of
 Skin rash, joint pain
 Loose motion, excessive thirst, vomiting, cold
preference, getting darker than before
 Sexual exposure, taking intravenous drug,
exposure to TB patient, travelling to malaria
endemic area
 Tooth extraction, recent surgery

9. History of past illness
• He is a diagnosed case of Bicuspid Aortic Valve
with Severe Aortic Regurgitation which was
diagnosed incidentally during evaluation of his
fever and weight loss at a divisional medical
college hospital 15 days ago

10. • Family history:
– All members of his family are enjoying good
health
• Personal history :
– Patient is non-smoker, non-alcoholic
• Socioeconomic history:
– Patient belongs to a lower class family

11. • Psychiatric history:
– Nothing significant
• History of immunization:
– Patient is immunized as per EPI schedule and took
3 dose of COVID19 vaccine

12. • Drug and treatment history:
– With the complains of fever and weight loss he
consulted several general and specialist physician
and treated with oral antibiotic.
– Currently patient is taking
• Tab. Metoprolol (25 mg), 1 tab BD
• Tab. Furosemide+Spironolactone (20+50mg), ½ tab OD

13. General Examination
• Appearance: Ill looking
• Body Built: Average
• Nutrition: Malnourished
• Decubitus: On choice
• Cooperation: Co-operative
• Anemia: Mild
• Jaundice: Absent
• Cyanosis: Absent
• Clubbing: Present
• Koilonychia: Absent
• Leukonychia: Absent

14. General Examination
• Edema: Absent
• Dehydration: Absent
• Bony tenderness : Absent
• Pigmentation: Multiple blackish pigmentation over lips and
buccal mucosa
• Lymph nodes: Not palpable
• Thyroid gland: Not enlarged
• Body hair distribution: Normal
• JVP: Not raised
• Pulse: 90 bpm, regular, High volume, collapsing
• Blood pressure: 98/40 mm Hg
• Temperature: 98 F
• Respiratory rate: 16 breaths/min

15. Systemic Examination

16. Cardiovascular System Examination
• Examination of the precordium:
• Inspection:
– There is visible cardiac impulse
– No Scar mark, deformity of chest or any other visible impulses
• Palpation:
• 1. Apex beat:
– Located in the left 5th intercostal space in the mid clavicular line
– Thrusting in nature
• 2. Thrill:
– Thrill is present over the left lower parasternal area, diastolic in nature
• 3. Left parasternal heave:
– Present
• 4. Palpable P2:
– Absent
• 5. Epigastric pulsation:
– Present

17. Cardiovascular System Examination
• Auscultation:
• 1. 1st and 2nd heart sounds- Audible in all four areas
• 2. Other heart sounds –Absent
• 3. Murmur:
– Early diastolic murmur, which is high pitched, blowing,
best heard in the left lower parasternal area, best heard
with patient bending forward and breath holding after
expiration
• 4. Added sounds:
– Absent
• 5. Lung Base Crepitation:
– Absent

18. Cardiovascular System Examination
• Quinke's sign: Present
• Duroziez's sign: Present
• Traube’s sign: Present

19. Gastrointestinal System Examination
• Per abdominal examination:
– Inspection:
• Abdomen is scaphoid, flanks are not full, umbilicus is
centrally placed, inverted
– Palpatiton:
• Deep palpation reveals tenderness over the suprapubic
region, no organomegaly present
– Percussion:
• Tympanic all over the abdomen
– Auscultation:
• Bowel sound: present
• Added sound : absent

20. Other systemic examination revealed no
abnormality

21. Salient feature
 Md. Tamim, 19 years old, normotensive, non-diabetic,
known case of Bicuspid Aortic Valve with Severe AR,
Muslim male admitted to BSMMU with the complains
of fever and weight loss for 10 months.
 According to the statement of the patient fever was
high grade, remittent in nature, highest recorded
temperature 105 degree Fahrenheit, associated with
chills and rigor, subsided by taking anti pyretic
medication with sweating, not associated with any
evening rise of temperature or night sweat but
associated with burning sensation during micturition
and frequency of micturition.

22. Salient Feature
• He also complains of Unintentional weight loss of 10 kg
over 10 month associated with loss of appetite.
• On query he gives history of palpitation which is
Spontaneous, Persistent, not relieved by any specific
measures but associated with occasional breathlessness
and chest pain
• He gives no history of Skin rash, joint pain, loose motion,
excessive thirst, vomiting, cold preference, getting darker
than before, sexual exposure, taking intravenous drug,
exposure to TB patient, travelling to malaria endemic
area, tooth extraction or recent surgery.

23. Salient Feature
• Patient is taking Tab. Metoprolol (25 mg), 1 tab BD and
Tab. Furosemide+Spironolactone (20+50mg), ½ tab OD
• On general examination patient is
• ill looking, mildly anemic, clubbing present
• Edema, cyanosis absent
• Multiple blackish pigmentation over lips and buccal
mucosa
• JVP: Not raised
• Pulse: 90 bpm, regular, High volume, collapsing
• Blood pressure: 98/40 mm Hg

24. Salient Feature
• Examination of the precordium reveals
• Visible cardiac impulse
• Apex beat is located in left 5th intercostal space along
the mid clavicular line, thrusting in nature
• Thrill is present in left lower parasternal area, diastolic
in nature.
• 1st and 2nd heart sounds- Audible in all four areas
• There is an early diastolic murmur, which is high
pitched, blowing, best heard in the left lower
parasternal area, with patient bending forward and
breath holding after expiration.
• Lung bases clear
• Quinke's sign, Duroziez's sign, Traube’s sign: Present

25. Salient Feature
• Per abdominal examination reveals
• Tenderness over the suprapubic region,
• No organomegaly
• Other systemic examination reveals no abnormality

26. Provisional Diagnosis
Bicuspid Aortic Valve with Severe AR
and
• Infective Endocarditis or,
• Tuberculosis or,
• Recurrent UTI

27. Investigations

28. Before admission
• CBC with ESR:
12.10.2023
Hb 9.8g/dl
ESR 85
WBC 12800/cumm
RBC 3.86million/cumm
Platelet 520000/cumm
Neutrophil 82%
Lymphocyte 15%
MCV 80fl
MCH 24.9pg
MCHC 30.80g/L

29. Before admission
• RBS – 5.30mmol/L
• S. creatinine-0.63 mg/dl

30. Before admission
• Urine RME:
12.10.23
pH 5.5
Pus cell(/HPF) 4-6
Epithelial cell(/HPF) 6-8
RBC(/HPF) 2-5
Albumin Trace
Specific gravity 1010

31. Before admission
• X-ray Chest P/A view:
Normal Skiagram of chest

32. Before admission
• ECG:
• Left Ventricular Hypertrophy

34. Before admission
• Echocardiography:
• BAV with Severe AR, No AS
• Trace TR, PASP=34mmHg
• LV is dilated both in systole and diastole
• Good LV and RV systolic function(LVEF=62%)

37. After admission
• CRP:
• S. creatinine: 0.67 mg/dl
• Procalcitonin: 0.03mcg/L
• Mantoux test: Negative
20.10.23 26.10.23
22.79mg/L 39.76mg/L

38. After admission
• X-ray Chest P/A view:
Normal findings

39. After Admission
• USG of whole Abdomen:
Normal Study

40. After admission
• Blood C/S:
• Enterococcus Species in all three samples
• Urine C/S:
• No growth

43. After admission
• Echocardiography:
• BAV with raphe between NCC and LCC
• Prolapse of NCC to LV
• Calcification present in NCC and LCC with
vegetation, NCC(10mm*6mm), LCC(11mm*7mm)
• Global hypokinesia at rest
• Moderate LV systolic dysfunction(LVEF=44%)
• Dilated LV
• Severe AR

45. Final Diagnosis
• Infective Endocarditis
• BAV with Severe AR

46. Thank You