[HSF] Endocarditis with splenic infarct

[prasannasimha]

A 1 cm vegetation is supposed to be an indication by itself due to its 
embolic risk. What is practiced or practical is different from what is 
preached which is a different issue.
Prasanna
nand kejriwal wrote:
> 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
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