Page 59 - JSOM Winter 2025

FIGURE 2 Patient’s right foot with multiple tender erythematous
lesions.

FIGURE 3
Patient’s left
antecubital fossa
following brachial
vein excision.

bacteremia over the next 2 years, the patient was placed on
daily prophylactic doxycycline. The patient was eventually
medically retired from the Army due to complications from Together, these elements can obscure the diagnosis and com-
his IE. plicate patient management.

Discussion For our patient, this entire situation could have been avoided
with proper aseptic technique or by removing the contami-
Although the 2023 Duke Criteria updates aimed to improve nated line placed in the field once additional access was estab-
the sensitivity of diagnosing IE compared to the Modified lished at the civilian hospital. The patient had a heat stroke and
Duke Criteria in 2000, recognizing IE and including it on the does not remember the event leading to his hospitalization. Al-
index of suspicion remains challenging. The diagnostic conun- though in a contaminated field environment, complete sterility
drum of IE arises foremost from most patients presenting pre- and aseptic technique may not have been a top priority for the
dominately with a fever and few other classic clinical signs treating provider(s) because the severity of the patient’s pre-
indicating endocarditis. Only half of patients have a new de- senting injury necessitated aggressive stabilization. However,
tectable murmur on auscultation and most of the other classic earlier removal of his field IV once hospitalized in a controlled
skin findings taught in medical textbooks (Janeway lesions, environment was feasible to prevent a catheter-associated in-
Osler nodes, Roth spots) occur in less than 10% of patients. fection. This concept parallels battlefield environments that do
3
Our patient’s tender lesions are consistent with Osler nodes, not always allow for ivory tower medicine due to tactical con-
painful lesions caused by immune complex deposits in vessels straints, limited supplies, and immediate life-threatening injury
and tissues. The primary pathologic criteria of isolating mi- patterns. Military providers must consider patient optimiza-
4
croorganisms that cause IE through two sets of blood cultures tion to include niduses for infection once medically and tac-
(or three sets if a nontypical organism) additionally leads to tically feasible to reduce morbidity. Further, bad habits in IV
delayed diagnosis due to culture growth or negative results placement should be broken early in training scenarios, such
if the patient has already received antibiotics. While the new as placing the Luer lock connector in the mouth for equipment
Duke microbiologic major criteria add immunologic and nu- control, which can inappropriately seed the IV with bacteria.
cleic acid-based techniques for the identification of bacteria From a foundational medical perspective, these concepts are
that do not grow on typical cultures (Coxiella burnetii, Tro- evident but were missed in our patient’s course of care by mul-
pheryma whipplei, or Bartonella species), this still requires the tiple levels of providers, either due to poor documentation or a
treating providers to have an early suspicion of IE to order lack of understanding of the environment in which he received
these tests. Furthermore, the sensitivity of TTE is often limited his initial treatment.
compared to TEE (21% vs. 86% respectively), and a TEE typi-
cally takes extensive coordination, making it difficult to detect
heart valve vegetations or abscesses in a timely manner. The Conclusion
5,6
addition of cardiac computed topography to the major imag- IE is rare in otherwise healthy soldiers. When the tactical set-
ing criteria with the 2023 Duke Criteria provides a valuable ting allows, prehospital providers must practice aseptic tech-
adjunct to the TEE for paravalvular lesions but still has limita- niques and advocate for their patients when other medical
tions in diagnosis and is only moderately more sensitive than a providers do not understand the potential consequences of the
TTE. Moreover, on presentation, patients likely will not meet field environment.
3
any of the major Duke Criteria typically associated with the
condition (positive imaging or microbiologic testing), lead- Acknowledgments
ing to further ambiguity and potentially delaying appropriate The authors would like to acknowledge CPT (Ret) Josh
treatment. Lastly, in deployed settings, blood cultures, nucleic Urnezis, the patient described in this publication. He provided
2
acid testing, and TEE capabilities are a rarity making this chal- images of his physical exam findings and assisted with accu-
lenging diagnosis even more difficult for military providers. rately reporting his condition and treatment.

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