Case Report: Early Valvular Repair of Rothia mucilaginosa Endocarditis with Intraparenchymal Hemorrhage from Septic Emboli.

INTRODUCTION: Rothia mucilaginosa is a rare cause of endocarditis, typically seen in intravenous (IV) drug users who use needles contaminated with saliva. However, it is rare in individuals who are immunocompetent, have no history of valvular disease, or have not undergone valvular repair. Definitive management of R mucilaginosa endocarditis is valvular repair, but this procedure can be delayed in the setting of intracranial hemorrhage.

CASE REPORT: We document the case of a 35-year-old male IV drug user who developed R mucilaginosa endocarditis, resulting in severe neurologic sequelae due to septic emboli. The patient presented to the emergency department (ED) where work-up revealed a clinical presentation consistent with endocarditis resulting in septic emboli. He was later admitted to the neurosurgical and cardiac intensive care units, where he underwent thrombectomy, monitoring of his intraparenchymal hemorrhage (IPH), and mitral valve repair. This case highlights the patient's functional neurologic outcome following delayed mitral valve repair due to IPH.

CONCLUSION: This case report highlights a rare form of R mucilaginosa endocarditis recognized in the ED, with a hospital course including thrombectomy, IPH monitoring, and mitral valve repair. The patient had progressive neurologic sequelae given delayed mitral valve repair due to concerns that procedural heparinization would worsen his IPH. Given functional decline, the patient underwent mitral valve repair on hospital day six without worsening of his IPH, demonstrating that current guidelines to delay mitral valve repair by four weeks in the setting of intracranial hemorrhage may be too strict for patients who are high risk for continued showering of septic emboli.