When the Heart Strikes the Spine: Spinal Cord Infarction Mimicking Longitudinally Extensive Transverse Myelitis (LETM) in Infective Endocarditis

Infective endocarditis (IE) is a serious infection of the endocardial surface of the heart that is associated with significant morbidity due to systemic embolic complications. Neurological involvement is well recognized but most commonly manifests as ischemic stroke or intracranial hemorrhage due to embolic events. Complete spinal cord infarction as an initial presentation of IE is rare and may mimic acute myelopathy or longitudinally extensive transverse myelitis (LETM), leading to diagnostic challenges. We describe a patient who presented with an acute-onset motor weakness and sensory deficits suggestive of LETM. Initial neuroimaging findings were consistent with LETM. However, further evaluation with blood cultures and echocardiography revealed IE with valvular vegetations, indicating an embolic source and explaining the neurological presentation as spinal cord ischemia secondary to IE. The patient was managed with the timely initiation of appropriate intravenous antimicrobial therapy along with supportive care. This case highlights the importance of considering an underlying embolic etiology in patients presenting with LETM-like acute myelopathy and emphasizes the role of early recognition and timely treatment in improving outcomes and preventing further complications.