Chandrasekhar Sanjay, Lee Dae Hyun, Patel Nidhi, Bassily Emmanuel, Chen Allan
Cardiology, University of South Florida, Tampa, USA.
Cardiology, Orlando Health Heart Institute, Orlando, USA.
Cureus. 2021 Aug 27;13(8):e17494. doi: 10.7759/cureus.17494. eCollection 2021 Aug.
A 74-year-old male with a past medical history of mechanical aortic valve replacement presented with abdominal pain and fever. Blood cultures revealed methicillin-resistant (MRSA) and the patient was started on target antibiotics. Initial transthoracic echocardiogram and transesophageal echocardiogram (TEE) did not show any vegetations or significant valvular regurgitation. No other sources of infection were identified. Five days after the initial TEE, a repeat TEE revealed new areas of thickening and echolucency seen anterior to the mechanical aortic valve, suggestive of aortic root abscess (AoRA). It also extended down the mitral-aortic intervalvular fibrosa and was associated with mitral valvular vegetation. Due to worsening clinical status and persistent bacteremia on appropriate antibiotics, a high index of suspicion for infective endocarditis (IE) remained after the initial TEE. As such, the repeat TEE was obtained only five days after and demonstrated clear evidence of rapidly growing endocarditis and abscess formation. This case uniquely demonstrates how rapid MRSA endocarditis may progress and emphasizes its high mortality. This case highlights the importance of a low threshold for repeat imaging when the index of suspicion for endocarditis remains high despite negative imaging.
一名74岁男性，有机械主动脉瓣置换病史，出现腹痛和发热。血培养显示耐甲氧西林金黄色葡萄球菌（MRSA），患者开始使用针对性抗生素治疗。最初的经胸超声心动图和经食管超声心动图（TEE）未显示任何赘生物或明显的瓣膜反流。未发现其他感染源。初次TEE检查五天后，再次TEE检查发现机械主动脉瓣前方出现新的增厚和无回声区，提示主动脉根部脓肿（AoRA）。它还延伸至二尖瓣 - 主动脉瓣间纤维，与二尖瓣赘生物相关。由于临床状况恶化且在使用适当抗生素的情况下持续存在菌血症，初次TEE检查后对感染性心内膜炎（IE）的高度怀疑仍然存在。因此，仅在五天后进行了再次TEE检查，结果显示有明确证据表明存在快速进展的感染性心内膜炎和脓肿形成。该病例独特地展示了MRSA感染性心内膜炎的快速进展方式，并强调了其高死亡率。该病例突出了尽管影像学检查结果为阴性，但当对心内膜炎的怀疑指数仍然很高时，重复成像的低阈值的重要性。
