Convexal Subarachnoid Hemorrhage Caused by Infective Endocarditis in a Patient with Advanced Human Immunodeficiency Virus (HIV): The Culprits and Bystanders

Abstract

Patient: Male, 52-year-old Final Diagnosis: Infective endocarditis • ischemic stroke • subarachnoid hemorrhage Symptoms: Altered mental status • cough • generalized weakness • shortness of breath Medication: Vancomycin and piperacillin-tazobactam Clinical Procedure: — Specialty: Neurology Objective: Rare disease Background: Convexal subarachnoid hemorrhage (cSAH), a rare form of non-aneurysmal subarachnoid hemorrhage, is confined to cerebral convexities without extension into basal cisterns or ventricles. Typical presentation includes thunderclap/progressive headache or transient focal neurological symptoms; rare manifestations include seizures, intractable vomiting, or altered mental status. Here, we report the first case of convexal subarachnoid hemorrhage and multifocal ischemic lesions caused by infective endocarditis (IE) in a treatment-naïve advanced HIV patient. Case Report: A 52-year-old HAART-naïve, HIV-positive, African American man presented with altered mental status, shortness of breath, nonproductive cough, and generalized weakness. His past medical history was significant for congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease (noncompliant with hemodialysis). Head computed tomography (CT) showed an isolated sulcal hemorrhage in the mid-left frontal lobe. Fluid-attenuated inversion recovery/gradient recalled echo sequences confirmed a hemorrhage in the left-mid-frontal sulcus, and diffusion-weighted imaging revealed multifocal bilateral ischemic lesions. Transesophageal echocardiography exhibited mitral valve vegetations. Multifocal ischemic lesions and cSAH caused by infectious endocarditis were confirmed. Initiation of intravenous vancomycin and piperacillin-tazobactam allowed the patient to have resolution of his altered mental status. A head CT 5 days later revealed the resolution of cSAH. Conclusions: Infective endocarditis should be considered as an underlying etiology of cSAH, especially when present with multifocal ischemic lesions. Risk factors contributing to the development of cSAH in the IE patient population should be explored in future studies. HIV has not been previously reported in this subgroup and its prevalence should be considered. The prognosis for cSAH in relation to IE is generally favorable.

The First Case Report of Community-Acquired Infective Endocarditis Due to Sequence Type 1223 Staphylococcus argenteus Complicated with Convexity Subarachnoid Hemorrhage

“…Although the specific mechanism by which IE causes cSAH is not well understood, several previous studies have revealed that cSAH is associated with IE. [21][22][23] In a retrospective study including 240 IE patients, Boukobza et al reported 31 IE cases (13%) with complicated cSAH that frequently occurred in middle-aged patients. They also reported that the majority of causative pathogens were Streptococcus spp.…”

Nonaneurysmal subarachnoid hemorrhage associated with COVID-19 infection: A case report

“…Numerous reports of viral infections and nonaneurysmal SAH have been associated with COVID-19 caused by SARS-CoV-2,[ 1 - 4 , 6 , 7 , 9 , 12 , 16 , 17 , 23 , 24 ] while some have been associated with other viruses including human immunodeficiency virus, herpes simplex virus, Epstein–Barr virus, Jamestown Canyon virus, and varicella zoster virus. [ 10 , 15 , 21 , 25 - 27 ] Interestingly, there have been no reports of nonaneurysmal SAH caused by coronaviruses other than SARS-CoV-2, such as severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1 or simply SARS-CoV) and Middle East respiratory syndrome coronavirus. As such, the true affinity of SARS-CoV-2 with cerebral vessels remains unknown in spite of an increasing number of reported cases.…”