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Seen in the ED: Positive Blood Culture


A man in his mid-60s presents after 1 month of intermittent fevers; recent blood cultures were positive for oral flora. Follow the ED course--can you make the diagnosis?

Patient history. A man in his mid-60s is sent to the hospital by his primary care clinician for 1 month of intermittent fevers without any other associated symptoms. Results of recent blood cultures were positive for oral flora. Since he has a chronic murmur and had been to the dentist about 6 weeks ago, the primary clinician sent him in for evaluation for possible endocarditis.

The patient denies any recent travel or use of any recreational drugs now or in the past. He has a history of CAD s/p stent as well as a murmur since childhood and takes metoprolol, aspirin, and clopidogrel.

Vital signs and physical examination. Vital signs are normal, but temperature is 98.9°F orally. Physical exam is normal except for a systolic murmur.

Initial diagnostic testing. ECG, CBC, and BMP all are normal.

Emergency department course:

  • The patient developed a mild generalized headache in the ED that resolved with acetaminophen but about 2 hours later it returned and gradually became severe.
  • A brain CT was ordered.
  • Prior to CT the patient became unresponsive and was noted to have clonus. The left pupil was enlarged to 6mm with the right ~3mm.
  • The patient was intubated prior to CT with fentanyl for ICP control and lorazepam for sedation.

What is the most likely diagnosis?

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