Abdominal angina as the presenting symptom in bacterial endocarditis. Daniel Suders DO, Tom Waltz DO, Adel Frenn MD, Demetrio Agcaoili MD Ohio Valley Medical Center Case This is a 61 year old male who presented with 50 pound weight loss over five months, abdominal pain, poor oral intake, general fatigue and malaise. Abdominal pain was described as intermittent cramping pain, it was worse with eating, which lead to his poor appetite and weight loss. Prior work-up for this complaint by Gastroenterology included EGD and HIDA scan. These tests showed Barrett’s esophagus and biliary dyskinesia. He was sent to a surgeon and underwent cholecystectomy. Pathology showed chronic cholecystitis, but after recovery from surgery, his symptoms were unchanged. Upon questioning, he did relate some dental work followed by a sinus infection prior to the start of his abdominal symptoms. Past medical history included CAD, atrial fibrillation, HTN, and hyperlipidemia. Literature Cited: 1. Misawa, Sakano, et al. Septic embolic occlusion of SMA induced by mitral valve endocarditis. Annals Thoracic Cardiovascular Surgery 2011; Vol. 17, No. 4: Double valve replacement and reconstruction of the intravalvular fibrous body in patients with active infective endocarditis. European Journal Cardiothoracic Surgery Guler, Sokmen, et al. Infective endocarditis developing serious multiple complications. BMJ Case Reports 2013: doi: /bcr Kim, Park, et al. Long-Term Results of Aortomitral Fibrous Body Reconstruction With Double-Valve Replacement. Ann Thorac Surg 2013;95: ACOI Annual Convention and Scientific Sessions 2013 Poster Presentation by Daniel J Suders DO Case The patient was admitted and found to suffer from acute renal failure, acute anemia, and hemoccult positive stools. A colonoscopy was performed and showed evidence of ischemic colitis. Blood cultures returned positive for alpha streptococcus. Echocardiogram showed an aortic valve vegetation, and TEE confirmed an intravalvular abscess between the aortic and mitral valves. The size of the vegetation was estimated at 3x3 cm. He was treated with IV Rocephin and Vancomycin. The cardiac surgeons at our center were uncomfortable with the complexity of the surgery he would need, and recommended transfer to a tertiary center. He was transferred to Cleveland Clinic, where he underwent debridement and replacement of the aortic valve, mitral valve and intervalvular fibrosa. This surgery in itself is relatively rare, and has only been performed since In the end, he did well, and was able to be discharged to home. Of note, no one on the case appreciated a heart murmur, despite the large size of the vegetation. Some of the more commonly seen embolic phenomena in endocarditis include neurological symptoms, secondary to cerebral septic emboli and pulmonary infarcts secondary to septic emboli to the lungs. This patient did not show signs of either, but was found to have ischemic colitis, suspected to be secondary to septic emboli to the mesenteric arteries. While this has been documented in the literature, it is very rare. We believe that the intermittent abdominal pain that went on for months was likely caused by intermittent embolic occlusion of the mesenteric arterial system, causing abdominal angina. The overall vagueness of his symptoms was a challenge for everyone on the case. During his long outpatient workup, a blood culture had never been checked, despite continued intermittent fevers. Even during the admission where the diagnosis was made, it took a few days to discover the true source of his symptoms. During which some of the sub- specialists were chasing down other causes of his symptoms. Discussion While the symptoms the patient was experiencing are common to subacute endocarditis, this diagnosis was not considered for many months. He exhibited several of the Duke’s minor criteria, including fever, renal failure suspected to be secondary to glomerulonephritis, and evidence of major arterial emboli. Of course, the diagnosis of endocarditis was definitive after the positive blood cultures and obvious vegetation on TEE. Conclusion Endocarditis is a relatively uncommon cause of febrile illness, but blood cultures should be sampled in any febrile illness, particularly once it becomes protracted. Abdominal pain, mesenteric ischemia, and renal failure are all possible presenting symptoms of embolic endocarditis, though less common than neurologic changes or pulmonary emboli. A good, thoughtful, osteopathic internist, following the osteopathic tenets, should consider the patient as a whole in a case like this to make the appropriate diagnosis. We often fall into the trap of containing the work up to one organ or system, which did occur in this case for some time. For example, this patient had even underwent a cholecystectomy for these abdominal symptoms, before the true etiology was discovered. This also illustrates the role of the internist as the informational hub, which is essential to the coordination of patient care. This was an interesting and challenging case that illustrates the importance of a thorough history and physical and the need to consider the patient as a whole.