Infective Endocarditis in a Pediatric Patient

A previously healthy 11-year-old boy presented to the emergency department (ED)4 at Children's Hospital Los Angeles (CHLA) with a 3-week history of intermittent fever. Two weeks before admission, he was seen at an outside hospital for his bouts of fever. At the outside hospital, chest x-rays and urine workup were within reference intervals and he was discharged with a 5-day oral azithromycin prescription for presumed bacterial infection. In the ED at CHLA, the patient appeared to be well and in no distress. His initial vitals included the following: temperature, 37.4 °C; heart rate, 133 beats/min; blood pressure, 108/77 mm Hg; and respiratory rate, 20 breaths/min. On physical examination, small lymph nodes at the posterior neck were identified, but the rest of his examination parameters were within reference intervals. Laboratory investigations revealed mild leukocytosis [white blood cell count, 16.16 K/uL (4.31–11.00 K/uL); neutrophils, 88.4%], increased erythrocyte sedimentation rate [ESR; 102 mm/h (1–10 mm/h)] and high C-reactive protein (CRP) level [3.7 mg/dL (0.0–0.9 mg/dL)]. Urinalysis and chest x-ray were normal. After 2 sets of blood cultures were obtained, the patient was started on empiric antibiotics—vancomycin, 500 mg intravenous (IV), and ceftriaxone, 2000 mg IV, and he was admitted to the hospital for further evaluation. One set of blood cultures (aerobic and anaerobic) obtained …