Stroke, Fever, and Clot Microbiology Analysis: A Case Report

Infective endocarditis (IE) is a rare but serious life-threatening disease, often presenting with highly variable clinical symptoms. Risk factors for this condition include valvular heart disease, age, medical procedures, dental procedures, and intravenous drug use. Patients with IE may exhibit valve dysfunction, heart failure, or neurological complications such as stroke, the latter being caused by an embolus originating from valvular vegetations that occlude more distal vessels in the cerebral circulation. Diagnosis is based on the modified Duke criteria. We report a case of a 20-year-old male patient who presented to the emergency department with the acute onset of aphasia, right-sided hemiparesis, and fever. Neurological examination revealed a National Institute of Health Stroke Scale score of 10, and computed tomography (CT) angiography confirmed a left middle cerebral artery occlusion. Since endocarditis was not known at the time of stroke diagnosis, the patient underwent thrombolysis. He then underwent thrombectomy with successful recanalization, and the retrieved thrombus was sent for microbiological analysis. Laboratory findings showed leukocytosis, elevated erythrocyte sedimentation rate, and elevated C-reactive protein, and both blood and thrombus cultures were positive for Streptococcus anginosus. An echocardiogram revealed a vegetation in the mitral valve, confirming the diagnosis of IE. The patient was treated with ceftriaxone, rifampicin, and gentamicin according to antibiotic susceptibility results, and underwent mitral valve replacement surgery, demonstrating a good clinical outcome with recovery from the neurological deficits. This case highlights the importance of considering the diagnosis of IE in patients presenting with stroke and fever, as ischemic stroke can be an embolic complication of IE. It also emphasizes the potential role of microbiological analysis of clots retrieved through thrombectomy in identifying the infective agent, especially in patients where blood cultures are negative or inconclusive. Such identification might help select appropriate antibiotic therapy, although more studies are required to better define its role in patient care.