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PO.13 Infective endocarditis presenting with lymphocytic meningitis

A 64-year-old lady presented with an acute onset febrile illness followed by a seizure and subsequent confusion. Examination revealed a vasculitic rash but no focal neurological deficits. She was noted to have a widespread symmetrical inflammatory polyarthritis. Investigations revealed thrombocytopaenia, acute renal failure and acute phase response with CRP >380. MRI brain imaging demonstrated small ischaemic lesions in the right parietal lobe, CSF demonstrated lymphocytic meningitis with low glucose. She was treated with cefotaxime, ampicillin and aciclovir with no improvement. Prednisolone was added to antimicrobial therapy in view of vasculitic features and this resulted in significant symptomatic improvement. 10 days into her treatment the patient developed acute left ventricular failure and repeat echocardiogram showed new aortic regurgitation. A presumptive diagnosis of culture negative endocarditis was made and she was transferred to the cardiothoracic unit and later underwent aortic valve replacement. The macroscopic findings were in keeping with acute endocarditis. With further antimicrobial treatment her condition continues to improve. Although vasculitic features are well recognised with bacterial endocarditis we have not come across a case in literature with such prominent immunological features. We feel this case highlights the diverse presentation of this rare but important disorder.