Question: rapid neurological deterioration

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This Spot the Diagnosis article refers to ‘Answer: rapid neurological deterioration’, by N. Bradt et al., https://doi.org/10.1093/ehjacc/zuae061. A 52-year-old man was referred to the intensive care unit of our tertiary care centre in September 2023 due to progressive neurological impairment. The patient was known to have a hypertrophic cardiomyopathy with a proven heterozygote pathogenic mutation in the MYBPC3 region. Due to an episode of non-sustained ventricular tachycardia, an implantable cardioverter-defibrillator was implanted in 2014. In September 2019, the patient received six inappropriate shocks due to atrial fibrillation. Electrophysiological studies demonstrated both atrial fibrillation and a cavotricuspid-dependent atrial flutter. A combined ablation with pulmonary vein isolation and cavotricuspid isthmus ablation was performed. Redo-ablation was performed respectively in April and August 2023 due to recurrent episodes of atrial fibrillation. The patient was initially admitted to another hospital with fever, chills, and haemoptysis. The initial diagnosis of a community-acquired pneumonia was made, and the patient was started on intravenous antibiotics with amoxicillin–clavulanic acid. The next day, the patient developed neurological impairment with left-sided motoric hemiplegia. An initial computed tomography (CT) scan of the brain showed no signs of a haemorrhagic or ischaemic stroke. On the second day, the patient’s inflammatory markers rose to a C-reactive protein level of 360 mg/L. The blood cultures were positive for Streptococcus anginosus and Gemella species. Later that day, the patient developed aphasia combined with left-sided facial paralysis. A new CT scan of the brain revealed multiple ischaemic lesions. On clinical examination, purpuric skin spots were observed on his left foot and right cheek. Figure 1 shows the electrocardiogram taken at our hospital. The images of the transthoracic echocardiography as well as the CT scan of the brain can be seen in the supplementary materials. Electrocardiogram taken upon transfer to our hospital. What is the most appropriate next step besides continuation of antibiotic treatment? Transoesophageal echocardiography Lead extraction CT scan of the thorax Watchful waiting Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online. There are no financial interests. The data underlying this article are available in the article and in its online supplementary material.

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