Abstract 4368291: A Rare Case of Haemophilus influenzae Endocarditis Leading to Valvular Cardiogenic Shock and Acute Respiratory Distress Syndrome

Introduction: Haemophilus influenzae is a rare cause of native valve infective endocarditis. We present a case of double valve endocarditis with initial focal neurologic findings and subsequent progression to cardiogenic shock requiring emergent surgical intervention. Description of Case: A 41-year-old male with a history of hypertension presented with headache, dizziness, and blurred vision, with rapid progression to global aphasia. Initial neurologic imaging revealed a subarachnoid hemorrhage of the left posterior, frontal, and parietal sulci. Transthoracic echocardiogram showed a bicuspid aortic valve with moderate aortic and mitral regurgitation and a 2.5cm mobile mitral valve vegetation. Digital subtraction angiography identified multiple pseudoaneurysms and a 2mm mycotic aneurysm. His intra-procedural course was complicated by acute hypoxic respiratory failure requiring emergent intubation and SCAI-C valvular cardiogenic shock. His course was further complicated by acute respiratory distress syndrome requiring lung-protective ventilation and stress-dose steroids. Transesophageal imaging revealed a new aortic root vegetation with worsening severe aortic regurgitation and mitral regurgitation. He remained febrile despite negative blood cultures and empiric antimicrobial treatment. A Karius Spectrum panel detected ceftriaxone-sensitive Haemophilus influenzae . Despite maximal inotropic support, antibiotics, and ventilator settings, he remained in refractory valvular shock and hypoxic respiratory failure. Emergent surgical intervention with Commando procedure additionally revealed an abscess extending into the aorto-mitral curtain, and the mitral valve, aortic valve and root, left atria, and left ventricular outflow tract was replaced and reconstructed.His post-operative course was complicated by high degree AV block requiring a leadless pacemaker and was discharged nine days later to acute rehabilitation. ` Discussion Haemophilus influenzae is culture-negative microbe that is a rare cause of double valve endocarditis. Karius testing allowed for identification and targeted antimicrobial therapy. However, despite maximal supportive therapy, correction of acute severe valvular cardiogenic shock required urgent surgery. The Commando procedure can be used for treatment of native double valve endocarditis and aorto-mitral curtain reconstruction.This case reinforces the essential role of a multidisciplinary care team in improving outcomes in critically ill patients.