IE was raised in the thread as it related to dental treatment. Therefore, I thought I would add to the reason that ender18D didn't focus on that possibility for the acute symptoms that this patient is experiencing based on his history.
Infective endocarditis (IE) is
extremely rare in the postoperative dental patient population. In certain conditions, it is a valid concern. If at risk, the military dental clinic would have supplied Ab premedication to the TS
before treatment began to prevent it. They would have also verified patient cooperation with Ab regimen before beginning treatment. Postoperative Ab therapy is
not indicated to prevent IE.
When I first got out of school, the fear of postop IE dictated that we gave antibiotic prohylaxis pre and postop to patient in all sorts of widespread patient populations from MVP with or W/O regurgitation, all forms of congenitial heart defects, history of rheumatic fever, past IE episode, history of cardiac stints, valve surgeries, prosthetics, A-fib, etc. Basically, it was "if in doubt, give them antiobiotics before and after treatment. This thinking has changed as the actual scientific data has been developed.
Currently, IE is at the highest risk in patients with a history of:
1-
prosthetic cardiac valve; risk 1:124,000
2-
prior documented incidence of IE, risk 1:95,000
3-
Heart transplant patients who develop cardiac valvulopathy
4-
past rheumatic heart disease; risk 1:142,000
***
our patient in this thread has none of these in his history
The only other patient populations that are at high enough risk to warrant true concern for IE are certain congenital heart defects in the following
specific groups:
1-
Unrepaired cyanotic CHD, including palliative shunts and conduits
2-
completely repaired CHD with prosthetic material during the first 6 months after surgery
3-
repaired CHD with residual defects at the site of the prosthetic patch (inhibits endothelialization)
Since our barrel chested, freedom fighter does not fit into these parameters, it is VERY unlikely that the diagnosis is
Infective endocarditis caused during a dental procedure or by his poor postoperative patient cooperation with antibiotics. Still hanging on to the likelyhood of our TS friend having IE??? What are the chances? Well, if he did in fact have mitral valve prolapse and experienced a very messy surgical procedure without the appropriate premed... his chances were still only 1:1.1 MILLION of getting IE postop to a dental visit. It is not even clear he had a heart murmor or any other even minor risk factor for IE from what I glanced at during the thread.
FWIW,
That would not only have been a Zebra, it would have been the ultra rare spotted, long neck blue throated zebra that is only found in far regions of Neverlandia.
BTW- there should be some simple, basic tests that could help identify problems in his oral cavity and S/S of recurrent infection other than running a fever if the patient is septic from a dental condition/visit/treatment.
Great thread ender18D.