key: cord-0821551-k0zzxffl
authors: Mantero, Vittorio; Rigamonti, Andrea; Basilico, Paola; Sangalli, Davide; Scaccabarozzi, Chiara; Salmaggi, Andrea
title: Stroke in a Feverish Patient with COVID-19 Infection and Unknown Endocarditis
date: 2020-09-09
journal: J Clin Neurol
DOI: 10.3988/jcn.2020.16.4.707
sha: a36ee1916fb489433cbba0aa916337c2caf37517
doc_id: 821551
cord_uid: k0zzxffl

nan

JCN transformation is significantly higher in patients with IE, and the rate of favorable outcomes is a significantly lower in these patients. 3 However, excluding this diagnostic hypothesis requires both a high index of clinical suspicion and the emergency availability of echocardiography, which is not considered in current guidelines as mandatory before thrombolysis. Thus, interpreting the clinical and chest-CT picture of the present patient as an expression of ischemic stroke in the context of COVID-19 infection led to underestimation of the alternative hypothesis of embolic stroke in IE.

In this patient, COVID-19 infection was a confounding element and we think that it was not connected to IE. COV-ID-19 infection may lead both to superimposed bacterial disease and to increased activation of procoagulant cascade. Actually, due to the increasing awareness of the thromboembolic risk in these patients, the current practice in our institution includes prophylactic low-molecular-weight heparin for at least 14 days even in ambulatory COVID-19 patients who are dismissed from the hospital and waiting isolated at home to receive the negative result for a nasal swab.

To conclude, clinical scenarios in acute-ischemic-stroke patients with fever are often complex, due to both the rapid decisions required and the difficulty in performing echocardiography on an urgent basis. The present case emphasizes the need for echocardiography in urgent practice to ensure the correct differential diagnosis on etiologies when deciding whether a patient with ischemic stroke should be subjected to thrombolytic therapy. In the present era of the COVID-19 pandemic, we think that the risk-and-benefit equation in fe-verish patients questions any rigid guidelines, also considering that there is evidence that fibrinolytic therapy in acute lung injury and ARDS improves survival. 4 

Vittorio Mantero https://orcid.org/0000-0002-1216-9853

The authors have no potential conflicts of interest to disclose.

When the heart rules the head: ischaemic stroke and intracerebral haemorrhage complicating infective endocarditis

Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature

Thrombolysis for ischemic stroke associated with infective endocarditis: results from the nationwide inpatient sample

Tissue plasminogen activator (tPA) treatment for COVID-19 associated acute respiratory distress syndrome (ARDS): a case series

None.