Infective Endocarditis Presenting as Subarachnoid Hemorrhage: An Appeal for Caution

Abstract

Spontaneous subarachnoid hemorrhage (SAH) as the presenting feature of infective endocarditis (IE) is rare. It has classically been described in association with the rupture of intracranial mycotic aneurysms (ICMA). Here we describe a very rare case of non-aneurysmal spontaneous SAH in a patient with IE. The patient originally presented with a headache and low-grade fever. Neuroimaging including computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed SAH. She was eventually diagnosed with streptococcus gallolyticus (formerly streptococcus bovis) IE. Through this case, we advocate consideration of the diagnosis of IE in patients with SAH so that there is timely recognition of this reversible but serious disease.

Neurosarcoidose: Relato De Caso Em Paciente Com Rebaixamento Do Sensório Associado a Neuropatia De Nervo Craniano, Cefaleia E Vasculopatia

“…The presentation of IE complicating SAH shown in our case is rare and described only in case reports (ASIF et al, 2017;BOUKOBZA et al, 2017;CHUKWUDELUNZU et al, 2002). SAH is mainly associated with rupture of infectious intracranial aneurysm, accounting for 2% to 4% of all IE cases and 5% to 12% of those with neurological manifestation (MORRIS et al, 2014;PETERS;HARRISON;LENNOX, 2006).…”

“…Neurological complications are present in the context of IE in 40% of patients (ASIF et al, 2017;SONNEVILLE et al, 2011;YANAGAWA et al, 2016). Clinical manifestations are diverse and include ischemic and hemorrhagic stroke, infectious aneurysm, meningitis, brain and spinal epidural abscesses and encephalopathy (CARNEIRO et al, 2019).…”

“…Early institution of treatment with appropriate antibiotic is known to be the basis of the right management of patients with SAH and IE (ASIF et al, 2017;NOVY et al, 2013). Cardiac surgical intervention, performed in about half of patients with endocarditis (HABIB et al, 2019;KANG, 2015), is also indicated for a significant portion of patients with neurological complication of the disease, but the best time for the intervention remains controversial, since the decision must take into account multiple risks -including recurrent embolism and hypotension worsening cerebral ischemia (NOVY et al, 2013).…”

Subarachnoid haemorrhage as a late complication of infective endocarditis: a case report

“…Neurological complications occur in 30-40% of cases of IE which include strokes, transient ischaemic attacks, intra cerebral haemorrhage (ICH), cerebral abscesses, spinal epidural abscesses, infectious intracranial aneurysms, mononeuropathy, seizures, meningitis and toxic encephalopathy (2). While ischaemic stroke is the most common neurological complication, intra cerebral haemorrhage constitutes 12-30% of the complications (2,3) However, asymptomatic micro bleeds due to immunologic vasculitis are increasingly being recognised as the commonest neurological complication (2).…”

Subarachnoid hemorrhage as the key to the diagnosis

“…Within patients with neurological complications of IE, 12-30% present cerebral hemorrhages due to: hemorrhagic transformation of ischemic strokes caused by septic emboli, rupture of mycotic aneurysms or vasculitis-induced cerebral microbleeds [1,2].…”