Not Just Another Vegetation: A Rare Complication of Infective Endocarditis

1University of Colorado, Denver, Aurora, CO

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 247

Case Presentation:

A 47‐year‐old man with a history of hepatitis C infection, hypertension, diabetes, and bicuspid aortic valve presented with 2 weeks of fevers, chills, and rigors. He was afebrile and hemodynamically stable at the time of admission. Cardiovascular exam revealed a regular rate and rhythm with no murmurs, and his lungs were clear to auscultation. His white blood cell count was 15 × 109/L, and blood cultures grew Streptococcus bovis. Transthoracic echocardiography did not show any vegetations; however, he was started on intravenous ceftriaxone for presumptive infective endocarditis. Three days into his hospitalization, he developed supraventricular tachycardia with a new left bundle branch block. Troponin I level at that time was 2 ng/mL. Subsequently, he complained of chest pain and shortness of breath. He developed flash pulmonary edema, became obtunded, and was emergently intubated and started on vasopressors for hypotension. A transesophageal echocardiogram revealed extensive, bulky thickening of all 3 leaflets of the aortic valve, in addition to a rounded nonmobile density beneath the left aortic cusp, suspicious for vegetation. Troponin I level peaked at 194 ng/mL. The patient was deemed a poor surgical candidate given his decompensated status and underlying chronic medical conditions. After discussions with the patient and family, he was transitioned to comfort care measures and was removed from the ventilator. He died 2 days later. Autopsy revealed a congenital bicuspid aortic valve with septic vegetation measuring 2.5 × 2.0 × 1.5 cm. The coronary arteries revealed mild atherosclerosis with no luminal stenoses identified. The myocardium revealed an area consistent with myocardial infarction of 3 days’ duration involving the entire left ventricular wall. His death was attributed to myocardial infarct resulting from obstruction of coronary artery ostia blood flow by a large septic vegetation on the aortic valve.

Discussion:

Myocardial infarction from coronary ostium occlusion is a rare complication of infective endocarditis. Previous cases have been reported in patients with coronary ostium occlusion by septic aortic valve vegetations, including instances of survival of patients who underwent timely surgical intervention with aortic valve replacement. Surgical management is indicated in patients with infective endocarditis who develop heart failure or have a high risk of heart failure, uncontrolled infection and in patients with a high risk of embolism.

Conclusions:

Coronary ostial occlusion should be considered as a potential complication of infective endocarditis, and all patients with infective endocarditis should be evaluated early in their clinical course for potential surgical intervention.

Disclosures:

C. Brown ‐ none; J. Youngwerth ‐ none; L. Langston ‐ none

To cite this abstract:

Brown C, Youngwerth J, Langston L. Not Just Another Vegetation: A Rare Complication of Infective Endocarditis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 247. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/not-just-another-vegetation-a-rare-complication-of-infective-endocarditis/. Accessed May 26, 2019.

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