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Erschienen in:
05.12.2017 | IMAGES
Rare cause of complicated prosthetic valve endocarditis
Erschienen in: Indian Journal of Thoracic and Cardiovascular Surgery | Ausgabe 3/2018
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A 29-year-old gentleman, employed in an animal farm, presented with a 6-month history of chronic fever, anorexia, and malaise. He had undergone aortic valve replacement with mechanical prosthesis for severe aortic stenosis due to bicuspid aortic valve at the age of 25. Clinical examination showed a normal jugular pulse, absence of cardiomegaly, normal prosthetic valve clicks, grade 3 ejection systolic murmur in the right second parasternal space, and non-tender hepatosplenomegaly. Labortory examination showed hemoglobin – 15.9 g/dl and a total count of 4900 cells/mm3 with a differential count of 49% polymorphs and 48% lymphocytes. Electrocardiogram showed a normal sinus rhythm with a PR interval of 150 ms. Echocardiography, transthoracic (Fig. 1a, Video 1), transesophageal (Fig. 1b, Video 2), and 3D (Fig. 1c, d, Video 3), revealed multiloculated aortic root abscess encircling the prosthetic valve. Blood culture grew Brucella melitensis in three consecutive samples and the same was confirmed by reverse transcriptase-polymerase chain reaction (RT PCR). Computed tomography (Figs. 2, 3, and 4) showed multiple outpouchings from the aortic root in close proximity to the valve. He has been initiated on treatment with rifampicin, doxycycline, cotrimoxazole, and streptomycin and is planned for aortic root replacement.
Fig. 1
1a shows transthoracic echocardiogram, 1c shows transesophageal echocardiogram in 48° rotation, and 1b and 1d show 3D transesophageal echocardiogram in 50° and 125° respectively. The multiloculated root abscess is well visualized (yellow arrow) in all of them
Fig. 2
3D volume-rendered image showing multiple lobular mushroom-shaped projections (in white asterisks) from the aortic root (notched green arrow) beneath coronary artery origin (straight yellow arrow). Left atrial appendage (curved red arrow) is seen in relation to the abscess. Streak artifact due to the prosthetic aortic valve is seen below the lobulations
Fig. 3
Axial post contrast CT angiogram with multiple lobulated projections (white asterisks) from the aortic root (straight yellow arrow). Relation of the right atrial appendage (blue star) and right ventricular outflow tract (red arrow head) to the abscess is seen
Fig. 4
Post contrast CT angiogram in short axis plane showing multiple lobulated projections (white asterisks) from the aortic root penetrating into the anterior wall of the left ventricle (LV). LV and streak artifact due to the prosthetic aortic valve are seen at the left ventricular outflow tract below the lobulations. Right ventricular outflow tracts (red arrow head) are noted superior and anterior to projections
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