A 29-year-old, previously healthy, non-HIV-infected Korean woman with a headache, blurred vision, and fever was admitted to our hospital. She had no history of intravenous (IV) drug use, vascular catheter use, acupuncture, or any significant medical condition such as congenital heart disease. She had gotten her earlobes pierced at a beauty salon six days before admission.
On admission, her body temperature was 38.4°C, her blood pressure was 108/63 mm Hg, her heart rate was 83 beats per minute, and her respiratory rate was 18 breaths per minute. The puncture sites on both earlobes were tender without signs of inflammation. Various skin lesions were noted: nonpruritic maculopapular rashes on her face, multiple Janeway lesions and pustules on her palms and soles, scattered pustules and microabscesses on her trunk and extremities, and subungual splinter hemorrhages on her fingers. Subconjunctival hemorrhage was also observed; a slit-lamp examination revealed multiple Roth spot-like retinal hemorrhages. Her lung sounds were clear, and no cardiac murmur was audible. Bilateral costovertebral angle tenderness was noted. No remarkable neurological abnormalities, except for blurred vision, were present. Laboratory tests revealed microscopic hematuria and the following values: white blood cell (WBC) count of 7170 cells/μL, platelet count of 60,000 cells/μL, C-reactive protein level of 260 mg/L, and an erythrocyte sedimentation rate of 10 mm/hour. A cerebrospinal fluid (CSF) analysis revealed red blood cell and WBC counts of 100 and 520 cells/μL (71% neutrophils and 2% lymphocytes), respectively; a CSF protein level of 84 mg/dL; and a glucose level of 61 mg/dL. An electrocardiogram revealed no abnormalities except for sinus tachycardia and right axis deviation. A chest radiography did not reveal any specific abnormality. A transthoracic echocardiography performed on day two of hospitalization revealed vegetation attached to the anterior chordae of her mitral valve; no intracardiac thrombi or structural cardiac abnormalities were observed. Brain magnetic resonance imaging revealed multiple embolic infarcts and leptomeningeal enhancement in both hemispheres of her cerebrum and cerebellum. An abdominal computed tomography (CT) scan revealed hypoattenuated lesions in her spleen and kidneys, suggesting the presence of multiple embolic infarcts with abscesses. S. aureus isolated from three sets of blood cultures was resistant to penicillin and oxacillin but was susceptible to gentamicin, clindamycin, erythromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. On the basis of the blood culture results, initial therapy with nafcillin and ceftriaxone was substituted with vancomycin in combination with gentamicin. On day eight of hospitalization, gentamicin treatment was discontinued.
On day six of hospitalization, our patient developed dyspnea and hypotension; a transthoracic echocardiography revealed a rupture of the papillary muscle of her mitral valve. An intra-aortic balloon pump was implanted, after which emergency cardiac surgery confirmed vegetation in the ventricular side of her P3 scallop and a rupture of her mitral valve chordae. Her entire mitral valve, including the base of her medial papillary muscle, was removed and replaced with a prosthetic valve. After eight weeks of vancomycin therapy, our patient was discharged without significant sequelae. Her facial rashes disappeared completely. In a transesophageal echocardiography performed before discharge, her prosthetic mitral valve was found to be functioning well; follow-up brain and abdominal CT scans indicated an improvement in her condition.