Correspondence

Case 29-2004: A Woman with Acute Onset of Chest Pain and Fever

N Engl J Med 2005; 352:309January 20, 2005

Article

To the Editor:

With reference to the recent Case Record (Sept. 16 issue)1 about a 75-year-old woman with acute onset of chest pain followed by fever, I would question the decision to initiate empirical levofloxacin treatment after specimens had been obtained for culture. The presentation included fever, systemic symptoms, cardiac symptoms, a murmur, and abnormal results of urinalysis in a patient with known (albeit mild) valve disease. Therefore, I would have thought that endocarditis would be at the top (or near the top) of the differential diagnosis, although the murmur was not typical of mitral regurgitation and no aortic regurgitant murmur was heard. There were no frank urinary symptoms, and the concentration of nitrites in the urine was not reported. With all this in mind, would there not have been an argument for either holding off on antibiotics and obtaining more serial blood cultures or immediately starting empirical treatment for endocarditis, depending on the patient's clinical state? The antibiotic therapy could then have been rationalized, if necessary, after the appropriate culture results and echocardiographic studies were available.

Andrew R.L. Medford, M.B., Ch.B.
Southmead Hospital, Bristol BS10 5NB, United Kingdom
andrew.medford@bris.ac.uk

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 29-2004). N Engl J Med 2004;351:1240-1248
   Full Text | Web of Science | Medline

Author/Editor Response

I agree with Dr. Medford that a rigorous approach to the care of a patient with suspected endocarditis should include either serial blood cultures without antibiotic therapy or, if the clinical suspicion is high, initiation of empirical antibiotic treatment after samples for cultures have been obtained. However, as detailed extensively in the discussion of the case presentation, this patient's visit to the emergency department was precipitated by acute chest pain associated with electrocardiographic changes. The patient was initially afebrile and had no cardinal signs or symptoms to suggest endocarditis. Levofloxacin was started in the emergency department because of the positive results of urinalysis and the potential need for an invasive procedure such as coronary angiography, which made it important to minimize the risk of infection associated with instrumentation. The implications of the patient's prodromal systemic symptoms were not fully appreciated until after she was admitted, when a fever developed and further clinical assessment suggested that endocarditis was a likely cause.

Claudia Chae, M.D., M.P.H.
Massachusetts General Hospital, Boston, MA 02114