Kassandra S. Carter

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are syndromes categorized by ANCAs and inflammatory infiltration of the walls of small and medium-sized blood vessels. These immunological conditions can destroy valves or result from infections triggering anti-proteinase 3 (PR3)-ANCA formation. Thus, differentiating infective endocarditis (IE) from AAV is consequential to appropriate management. This case highlights the importance of cardiac workup with AAV due to the presence of valve dysfunction from IE or as a result of the primary vasculitis 43-year-old man presented to clinic with a severe cough for three months, 35-pound unintentional weight loss, and lower extremity petechiae. Labs included an elevated creatinine and a positive ANCA and PR3. Blood cultures were ordered as part of diagnostic workup for PR3 ANCA vasculitis. They resulted positive for Streptococcus sanguinis. His echocardiogram demonstrated an aortic valve vegetation causing severe aortic insufficiency. Cardiovascular surgery performed a bio-Bentall aortic root replacement. His course was complicated by repeat cardiac surgery, cardiac arrest and renal failure. He was ultimately discharged two months later. At 6-month follow-up, he was overall well. His rheumatologic serology showed seronegativity of ANCA. Subacute endocarditis can be complicated by immune responses that mimic ANCA vasculitis. The European Society of Cardiology recommends evaluation by ECG and echocardiogram in vasculitides. The Vasculitis Foundation notes in refractory vasculitides, clinicians should evaluate whether infection is mimicking vasculitis. However, there is no guideline for routine blood cultures in AAV. Ultimately, treatment with antibiotics alone led to seronegativity of ANCA and resolution of pathology to the affected extracardiac organs.

Infective endocarditis is a common medical complication in patients with intravenous drug use (IVDU). staphylococcal infection is the predominant pathogen in left-sided endocarditis. Cardiac abscesses are more common in prosthetic valves. Should they rupture, they often create fistulous tracts in addition to prosthetic valve dehiscence, conduction abnormalities, and acute coronary syndrome. A 51-year-old man with history of IV drug use, methicillin-susceptible Staphylococcus aureus (MSSA) endocarditis, and bovine aortic valve replacement was treated for MSSA bacteremia and was discharged on dalbavancin. The transesophageal echocardiogram (TEE) was negative for abscess or vegetation. Three days later, he presented with fever, worsening mental status, and neurologic deficits with infarcts in the brain, lungs, spleen on imaging. TEE was negative for vegetation or abscess. After transfer to a quaternary care center four days later, TEE showed a large aortic root abscess that eroded the membranous ventricular septum resulting in a Gerbode defect. Then, he sustained a non-shockable rhythm cardiac arrest. The patient was transferred to the cardiac ICU where emergent TEE showed complete dehiscence of the septum and a loosely attached prosthetic aortic valve. After a second cardiac arrest and resuscitative efforts, the patient expired. This case highlights that inadequately treated infective endocarditis can rapidly progress and cause serious complications. If patients with prosthetic valves develop bacteremia and have negative TEEs, retrospectively-gated CTs should be obtained to evaluate for perivalvular extensions. Currently, there have been no published studies demonstrating patients with infective endocarditis who were treated with Dalbavancin that progressed to fistulous tracts. Further research is required to investigate the effectiveness of long-acting lipoglycopeptides, such as Dalbavancin, in treating infective endocarditis. This case demonstrates a rare, but a serious medical emergency that can arise in patients with prosthetic heart valves and positive blood cultures when not detected early and treated promptly.

Hepatitis C virus (HCV) infection is a major public health concern, with more than 58 million people chronically infected worldwide. The management of HCV, once the domain of specialists only, has been revolutionized by the advent of direct-acting antiviral therapies. To reduce the burden of HCV in the United States (US), emphasis is now being placed on the involvement of primary care physicians in the management of HCV patients. Inclusion of more primary care providers in the HCV diagnosis and treatment initiatives can assist in achieving the goal of HCV elimination, especially in the medically underserved areas. To actively engage in the management of HCV, primary care providers must understand its epidemiology, risk factors, natural history, current treatment regimen, and potential complications. This manuscript reviews these key areas, along with presenting the cost-effectiveness of treatment and evidence-based guidelines for follow-up care in adults with chronic HCV infection who have undergone HCV treatment. Equipped with this foundational knowledge about HCV management, primary care physicians can play a vital role in eliminating HCV.