Decoding the signs: Multifaceted presentation of infective endocarditis in an intravenous drug user

ABSTRACT

Infective endocarditis (IE) is a life-threatening infection resulting from the invasion of virulent microorganisms into the endocardial surface, often accompanied by significant morbidity and mortality if not promptly treated. We report a case of acute native valve IE in a patient with a history of intravenous drug use (IVDU). The patient presented with sudden-onset right-sided hemiparesis and altered mental status. Neuroimaging demonstrated an infarct in the left perisylvian cerebral cortex and insular region, corresponding to the left middle cerebral artery territory. Although the initial presentation resembled a typical stroke, clinical examination revealed a plethora of peripheral stigmata of IE, including Janeway lesions, Osler nodes, splinter hemorrhages, and Roth spots on fundoscopic evaluation. Abdominal imaging revealed multiple splenic and left renal infarcts. Transthoracic echocardiography identified mobile vegetations on the anterior and posterior mitral leaflets. Laboratory studies showed anemia, leukocytosis with neutrophilic predominance, and a markedly elevated C-reactive protein, while blood cultures remained negative. The patient was managed empirically with intravenous antibiotics, to which he responded: his fever resolved, sensorium improved, and he was discharged with residual right hemiparesis. This case underscores the diagnostic challenges in IE, especially in IVDU patients, and highlights the importance of early, aggressive management to reduce complications.