Cerebrovascular complication of infective endocarditis complicated with abdominal trauma

A 9-year-old boy presented to the emergency department with blunt abdominal trauma. Initial assessment was normal except for abdominal tenderness. On day 3, patient was transferred to the pediatric intensive care unit (PICU) for hemodynamic instability, and persistent fever despite antibiotic therapy. On PICU admission, his body temperature was 40 degrees C, heart rate was 160/min, respiratory rate was 36/min, blood pressure was 85/40 mmHg, and impaired consciousness was noticed. Complete blood count revealed hemoglobin of 11.5 g/dl, white blood cell count of 22,500/mm(3) and platelet count of 145,000/mm(3). Serum C-reactive protein and procalcitonin were 139 mg/dl and 8.80 ng/ml, respectively. Renal and liver function test results were normal. Cranial magnetic resonance imaging (MRI) was planned because of impaired consciousness and fever. On cranial MRI, multiple infarct areas were detected in both hemispheres and minimal hemorrhagic focus was found in the left temporal region. Because of the cranial MRI findings and fever echocardiographic examination was planned to exclude infective endocarditis. Transthoracic echocardiography successfully visualized mitral valve prolapse, 14x8 mm mobile vegetation on the atrial side of the posterior leaflet of the mitral valve, and severe mitral regurgitation. The left chambers were dilated. There was no evidence of a perivalvular abscess. On control transthoracic echocardiography, after 6 weeks of parenteral antibiotic treatment, there was no significant reduction of the visible vegetation therefore surgery was planned. Infective endocarditis should be considered in the differential diagnosis of fever of unknown origin. Especially during the early stage of disease, cranial MRI may be more useful to prevent fatal complications for patients with neurologic examination findings.