Heart Valve Infection Masquerading as Angolan Typhoid Fever

International Medicine Center is most often contacted because of concern about possible infection with a tropical disease agent. Often, it doesn’t work out that way.Wednesday, May 9, 2012, we received a call from the elderly father of 46yr-old John. His voice was urgent on the need for an appointment on Thursday for his son, en route to the U.S. from Angola, Africa. John was deathly ill, having had fever of unknown cause since April 26^th. He had been treated in a clinic in Angola with intravenous antibiotics, with no medical tests revealing a cause for his illness. The European physician attending him told John it was critical to get to medical expertise that might help him, and so he must leave Angola. Time was running out.John contacted his dad in his hometown, Little Rock, Arkansas. He told him to start the process of locating the right doctor. Meanwhile, John made the arduous connecting flights from Cameroon to Europe, and then to the U.S. Throughout he had fever, hard chills, and severe pain – especially in his head, chest, left ankle and thigh, left triceps muscle, and right arm. His ankle had become swollen and he could hardly bear weight on it.John’s father did what most of us would. He called the family physician they had relied on for decades. As he heard the frightening story and the unusual location of illness onset, Africa, their personal physician knew that the situation needed incisive diagnostic and treatment action that would not tolerate inexperienced decision-making. He particularly understood that the vast majority of U.S.-based physicians would not have any familiarity with esoteric tropical diseases that were some of the possibilities: typhoid fever, malaria, dengue fever. The family doc advised that John not come home. Little Rock did not have the required expertise. He should stop short, and stay in Dallas or Houston, TX.John’s dad went to work on the Internet. In his search for exotic disease expertise, he settled on the International Medicine Center (IMC) and Dr. Edward Rensimer. A quick phone call followed.As soon as the request was put before Dr. Rensimer, he asked for an ETA. It would be early afternoon Thursday when the flight should touch down. By the time they would arrive at the office, it would be approaching office closing time. However, Dr. Rensimer, aware of the ominous prospects, told his staff to have them come ASAP and we would see them.Upon entering the exam room, Dr. Rensimer found a hunched over, pale, dehydrated man, usually athletic, now frail and bundled in clothing to subdue the violent shakes. His concerned father, far from their home and now turning his critically ill son over to strangers, sat quietly and worried.After thoroughly questioning John, Dr. Rensimer carefully examined him. When did those dark spots appear on several finger tips of both hands? Did you know you have a heart murmur? Had you even been told you had a heart murmur? Dr. Rensimer reviewed the records from Cameroon. He then turned to John and his dad. “You must be hospitalized immediately. Though malaria and other diseases specific to Africa must be screened for, I believe you have bacterial infection of your heart valves [endocarditis], and that you are throwing infected blood clots to various parts of your body, causing the severe areas of pain, swelling, and discoloration. If I am right, this is a life-critical diagnosis. There is no time to lose.”John went straightway to the nearby acute care hospital where Dr. Rensimer is on the attending medical staff. Dr. Rensimer went by that evening to assure John was stable and that things were in motion. In the days ahead, cultures of John’s blood were growing the Staphylococcus aureus bacterium. Within 24 hours of admission, an emergency transesophageal echocardiogram performed by a cardiologist revealed a very dysfunctional “leaky” heart valve with bacterial vegetations on it. The valve was being destroyed rapidly by infection. Dr. Rensimer’s initial suspicion was verified and the patient was started on appropriate IV antibiotics. Subsequent studies showed John had showered his organs, two to his brain, with blood clots originating on the infected valve. It was miraculous that John had not died on the flights home or ultimately suffered any major organ damage. Unchecked, sudden, cataclysmic value rupture could lead to fulminant, intractable congestive heart failure and death.John was stabilized over several days in the Critical Care Unit. Eventually, with a team of expert medical and surgical specialists assembled by Dr. Rensimer, the destroyed, infected heart valve was successfully removed and a prosthetic valve was placed. John completed his medical treatment. After a short stay in Little Rock, he returned to his full-time career in Cameroon without restrictions. 8 months after his harrowing journey to the U.S., he returned to Houston and was judged to be infection free and with a normally functioning heart.Conclusion: At IMC, daily we are referred the extraordinary, the unorthodox, and the exotic/esoteric. The tropical medicine prospects posed by John’s case certainly qualified. However, just as U.S. trained and experienced doctors might “miss” such possibilities, IMC must always also consider more usual, but no-less ominous, afflictions. Staphylococcal endocarditis is an extremely uncommon, almost rare, disease anywhere and delay in diagnosis and initiation of proper treatment can be fatal. It is noteworthy that, despite the curve-ball of tropical disease considerations, the correct, critical diagnosis was made on clinical grounds (no testing) within 30 minutes of first contact in a patient with nothing by history to suggest he should have been at risk for endocarditis.Critical decision-making; real-time rapid, appropriate triage; targeted, appropriate testing and treatment; team assembly of the best specialists for the situation; and unsurpassed diagnostic expertise is what we do at IMC. We cut through the medical bureaucracy to get the job done.