Case Presentation: A 64-year-old male with gastric carcinoma and no prior cardiac history presented to the emergency room with altered mental status. On arrival, the patient was tachypneic, hypoxic, hypothermic, tachycardic and hypotensive. Initial investigations showed the patient had a leukocytosis with a left shift. Blood cultures taken upon arrival eventually grew E. Coli, thought to be from the urinary tract, although initial urinalysis was delayed until after initiation of antibiotics. Electrocardiogram showed sinus bradycardia with frequent premature atrial contractions. Chest X-Ray showed bilateral pleural effusions, which were eventually drained and found to be growing E. Coli. Transthoracic echocardiogram was done which showed moderate sized tricuspid valve vegetation with severe tricuspid regurgitation. The patient was thought to be in septic shock secondary to urinary tract infection and based on his other co-morbidities the patient decided to pursue hospice.

Discussion: Infective endocarditis (IE) is a focus of infection which effects the endocardium, specifically the heart valves or intra-cardiac devices. In prior decades IE was a disease primarily affecting patients with known rheumatic heart disease, prosthetic heart valves and intravenous drug abusers. Recently IE has been seen to health-care acquired in up to 25% of cases. In the United States, Infective Endocarditis effects 15 per 100,000 people. In a prospective study of 2781 patients, Staph Aureus was the most prevalent in non-IV drug abuser native valve endocarditis seen in 28%, followed by Streptococcus Viridians seen in 21%. The most common valves noted to be infected are the Mitral and Aortic in 41.1% and 37.6% of cases respectively. E. Coli is a very rare cause of IE as the organism does not readily adhere to heart valves as do the more common organisms seen in IE. In an 18-year prospective study done E. Coli accounted for 24% of total cases of bacteremia seen, however between 1900 and 2018 there have been less than 50 cases report of E. Coli endocarditis. E. Coli accounts for .5% of all IE cases, however the mortality of E. Coli IE is over 20% as opposed to other gram-negative bacteria which have a mortality of 4%. Advanced age, female gender, diabetes and presence of prosthetic heart valves, none of which were seen in our patient, have all been noted to be independent risk factors for patients with E. Coli IE. As with all bacterial IE cases, embolization, valve abscess, and atrioventricular blocks are common complications and should be monitored for.

Conclusions: Although a rare cause for IE, due to the high incidence of E. Coli bacteremia, IE should be considered as a complication in these patients.