Case Presentation: A 41-year-old woman with no significant medical history and eight weeks postpartum presented to the hospital with new left-sided facial numbness, right labial droop and intermittent numbness of the left arm one day prior to admission. She also had a near-syncopal episode and noticed her speech declined with drooling and facial asymmetry. Admission vital signs were normal. Physical exam was remarkable for left-sided facial asymmetry. Computed tomography of her head was negative for acute intracranial process. The patient was admitted with clinical concern for stroke. Tissue plasminogen activator was withheld due to delayed presentation. Soon after admission, she began having high-grade fevers, and her blood cultures returned positive for E. faecium. Transthoracic echocardiogram showed mild aortic insufficiency with grade three diastolic dysfunction. Magnetic resonance imaging of her head showed an acute/subacute infarct in the posterior division of the right middle cerebral artery (MCA) along with a 2.5-mm x 3.0-mm M3 fusiform aneurysm. Antibiotics were adjusted to vancomycin and gentamicin with high index of suspicion for infective endocarditis. A transesophageal echocardiogram (TEE) confirmed the presence of a 1.0-cm x 0.5-cm aortic valve vegetation with severe aortic regurgitation. After neurosurgical consultation, the patient underwent a cerebral angiogram revealing a mycotic aneurysm to the right M3 upper division MCA branch measuring 3.5 mm x 5.5 mm. She underwent aortic bioprosthetic valve replacement. Pathology evaluation revealed acute endocarditis growing E. faecium. The patient was discharged on long-term IV antibiotics. A repeat cerebral angiogram 20 days later showed resolution of the previous right MCA aneurysm.
Discussion: Infective endocarditis typically affects patients with valvular disease, prior rheumatic heart disease, prosthetic heart valves, intravenous drug abusers, or those with congenital heart disease. The most common causative organisms are Streptococcus and Staphylococcus species. The mitral valve is most commonly affected. E. faecium is a gram-positive species that typically colonizes the gastrointestinal and urogenital tracts making it a unique source of endocarditis. The only discernible source in this patient was her previous history of recent vaginal delivery with prolonged rupture of membranes, and suspected undiagnosed endometritis. Clinicians should maintain a high index of suspicion for stroke due to septic embolization in postpartum patients with acute neurological sequelae, and fever.
Conclusions: Postpartum infectious endocarditis is uncommon but holds a high mortality rate (11.1%). Patients presenting with neurologic deficits due to suspected septic emboli related to infectious endocarditis require timely diagnosis including early TEE and aggressive management to prevent further morbidity and mortality.