# Sepsis in the Structurally-Vulnerable Heart: A Case of Infective Endocarditis Masquerading as a Urinary Tract Infection in Pediatric Rheumatic Heart Disease

## TL;DR

A child with heart disease showed urinary infection symptoms, but physical signs pointed to a heart infection, highlighting the need for thorough exams in complex cases.

## Contribution

Highlights the diagnostic challenge of sepsis in pediatric patients with structural heart disease and the importance of physical exam in such cases.

## Key findings

- A pediatric patient with rheumatic heart disease presented with urinary symptoms but had physical signs of infective endocarditis.
- The case emphasizes the importance of a broad differential diagnosis in sepsis management for structurally vulnerable hearts.
- Physical exam findings were critical in identifying a cardiac source of infection despite initial urinary tract findings.

## Abstract

We present a case of a six-year-old female patient with a history of rheumatic heart disease (RHD), including mitral stenosis, mitral regurgitation, and pulmonary hypertension, who presented with fever, abdominal pain, and urinary findings. Although urinalysis and imaging confirmed bilateral pyelonephritis, the admitting provider noted concerning physical exam findings, including Janeway lesions and systemic features that raised suspicion for concurrent infective endocarditis (IE). In the context of her underlying valvular disease, these exam clues broadened the differential beyond a presumed urinary source and prompted an endocarditis-focused evaluation. This case underscores the enduring value of a careful physical examination, the need to maintain a wide diagnostic lens, and the importance of tailoring sepsis management for pediatric patients with complex cardiac comorbidities.