[HSF] Endocarditis with splenic infarct

[nand kejriwal]

Bob

The size of vegetation was 1 cm on initial echo.

The radiologist's opinion was that the appearance on the CT was in keeping
with infarct rather than an abscess. The ID consultant told us that the
spleen was "likely to clear" the organisms and would not need intervention.
The general surgeon also decided not to intervene at this stage. I therefore
replaced his valve today. There was a large vegetation on the P1 segment.
The gram stain from the vegetation was positive for gram +ve cocci. The
patient is doing well in the ICU. I have made everyone aware to keep a close
eye on the patient's abdomen.

*Is it customary these days to treat active endocarditis as an outpatient?*

Bob, It was a medical decision. This patient is from our township and has
ready access to medical facilities. I believe he was taught to
self-administer the antibiotics under close supervision of the district
nurses.

It appears from the responses that we do not have a consensus about the
management, if this patient had a splenic abscess. All three options were
suggested.

A. Splenectomy first, followed by mitral, as suggested by Michael (with the
risk that he could throw an embolus to brain)

B. Concomitant splenectomy as suggested by Prasanna (Risk of bleeding
splenic bed, as Tea mentioned)

C. Mitral followed by splenectomy a few days later as suggested by Bob (Risk
of seeding the prosthesis).

If this patient were referred before splenic infarct, what would you have
done?

In other words, is one cm vegetation an indication for surgery by itself,
even though he was well clinically and responding well to treatment with
normalisation of inflammatory markers?
Nand