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Bartonella henselae is a known cause of culture-negative endocarditis, which can be difficult to diagnose without a high clinical suspicion as specific diagnostic testing is required. We report the case of a 48-year-old male who presented with altered sensorium. A CT of the head showed left-hemispheric intracranial hemorrhage (ICH) likely secondary to ruptured left posterior cerebral artery (PCA) fusiform aneurysm seen on catheter cerebral angiogram, which was treated with endovascular embolization. The patient had a significant history of mitral valve prolapse; however, a transthoracic echocardiogram (TTE) was negative for any vegetation. Blood cultures were also negative. A year later, he presented with another ICH in the PCA territory and was found to have a new left distal PCA aneurysm, which was again treated with endovascular embolization. During that hospitalization, an echocardiogram showed myxomatous changes in the mitral valve with severe mitral regurgitation; however, blood cultures were negative. Further queries about the patient’s social history revealed that his spouse had been a cat owner in 2018, which prompted Bartonella henselae testing. The blood work showed elevated immunoglobulin G (IgG) titers for which he was placed on antibiotics. A follow-up catheter angiogram detected a new distal middle cerebral artery (MCA) M4 branch aneurysm treated with surgical clipping. The aneurysm tested positive for Bartonella henselae on polymerase chain reaction (PCR) testing. The patient subsequently underwent successful mitral valve replacement, which also was positive for Bartonella henselae on PCR testing; however, the Warthin-Starry stain was negative. This case demonstrates how a comprehensive history along with persistent evaluation for the underlying etiology of cerebral aneurysms can lead to the diagnosis of Bartonella henselae endocarditis. Cerebral mycotic aneurysms are known complications of endocarditis; however, the underlying infection can be difficult to diagnose. Recognition of this culture-negative endocarditis is critical for the appropriate treatment and management of patients to prevent morbidity and mortality.

Granulomatosis with polyangiitis (GPA) formerly known as Wegener's granulomatosis, is an anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). It is an uncommon disease with an estimated prevalence of 3 in 100,000 individuals with an equal distribution in both sexes. It is characterized by necrotizing granulomatous vasculitis that primarily affects the upper and lower respiratory tracts and the kidneys. Our patient's initial presentation was abdominal pain with no typical pulmonary or renal manifestations. Along the course of her hospitalization, she had multiple episodes of drop in hemoglobin and a steady increase in serum creatinine which was thought to be due to IV contrast nephropathy. With this case, we project the need for a high index of clinical suspicion to make an early diagnosis, especially in patients with atypical symptoms such as abdominal pain, and acknowledge the fact that IV contrast can possibly act as a second hit in underlying GPA, unmasking the active renal symptoms of the disease.

Background There has been an increasing trend in spinal infections (SI) in the U.S. over recent years. We sought to characterize the clinical and microbiological characteristics of SI at our hospital. Methods We conducted a retrospective review of SI over a 3-year period (2016 - 2019) utilizing ICD codes for data retrieval. Search terms included vertebral osteomyelitis, discitis, and epidural abscess. SPSS was used to compute the data. Results Of the initially screened 254 patients, 166 were included for analysis. Pertinent demographics were: mean age 59 years, male (61.4%), obese (44.5%), diabetic (25%), and drug-users (20%). Lumbosacral involvement was most common (69.8%); epidural abscess was present in 51.8% of patients. 15.7% had existing hardware. Overall, 79.5% (132/166) of cases had a positive culture from at least one site: blood 56.6% (94/166), CT-guided 83.5% (56/67), and surgical 51.1% (24/47). Of those patients with negative blood cultures, 22% (16/72) had pathogen recovery by CT-guided methods and 33% (24/72) from surgical specimens. S aureus was the most common pathogen isolated at 53.7% (71/132): MSSA comprised 38.6% (51/132) and MRSA 15.2% (20/132). The mean CRP (8.46 vs 15.83 mg/dL; P< 0.001), and WBC (9.08 vs 13.18 k/mcL; P< 0.001) were higher in culture-positive as compared to culture-negative cases. Mean ESR and temperature more than 100.4 oF did not differ significantly between these two groups. The 8-week median recurrence rate was 11.4%, of which nearly half had index S aureus bacteremia. Frequency of organisms isolated Association of mean inflammatory markers with positive cultures Conclusion Our study affirmed that S aureus is the most common cause of SI, of which MSSA was predominant. Epidural abscess was encountered in a substantial fraction of our case population. Leukocytosis and elevated CRP tended to predict culture-positive infection, whereas ESR and fever did not. As recommended in the IDSA Vertebral Osteomyelitis guidelines, blood cultures were obtained in all cases, which yielded positive results in more than half of patients. Pathogen recovery was further improved to nearly 80% with supplemental deep tissue sampling, thus highlighting the opportunity to enhance microbiological diagnosis at our institution. Disclosures All Authors: No reported disclosures