Munshi Rezwan, Pellegrini James R, Tsiyer Allen R, Barber Megan, Hai Ofek
Internal Medicine, Nassau University Medical Center, East Meadow, USA.
Cardiology, Nassau University Medical Center, East Meadow, USA.
Cureus. 2021 Sep 28;13(9):e18367. doi: 10.7759/cureus.18367. eCollection 2021 Sep.
Infective endocarditis (IE), commonly caused by , can affect multiple cardiac structures and lead to significant morbidity and mortality. We present a case of IE with extensive mitral valve involvement causing perforation and hemodynamic compromise. A 66-year-old Caucasian female presented to the emergency department for progressive altered mental status and lethargy. The patient and family denied history of intravenous drug use (IVDU) on interview. Physical exam revealed tachypnea, tachycardia, lethargy, and fluctuance in the right antecubital fossa draining serous fluid. Initial studies revealed a urinary tract infection, patchy bilateral opacities on chest x-ray, hypoxic respiratory failure, elevated lactate and cardiac markers, leukocytosis, and positive urine toxicology for opioid and benzodiazepine. She was intubated and admitted to the ICU, and later developed acute respiratory distress syndrome with requirement for vasopressors. Antibiotics were started, and blood cultures ultimately grew methicillin-sensitive . Coronavirus disease 2019 (COVID-19) results were negative. Cardiology was consulted for elevated cardiac markers that were due to myocardial injury in the setting of septic shock. A transthoracic echocardiogram showed a large mobile mass on the anterior mitral leaflet. Further evaluation with transesophageal echocardiogram revealed a large, mobile, and centrally necrotic vegetation on the medial portion of the mitral annulus extending to both the anterior and posterior leaflets. Doppler of the valve showed holosystolic retrograde ejection into the left atrium confirming a perforation. The patient was transferred urgently to a cardiothoracic surgery capable center for operative intervention on the mitral valve. IE is most commonly caused by and seen in highest rates among patients with a prosthetic valve, congenital heart disease, and intracardiac device. However, roughly 50% of IE occurs in patients without any valvular disease. Other risk factors include IVDU, valvular disease, and prior history of endocarditis. Clinical diagnosis of IE is made using the Duke's criteria, with echocardiogram and bacteremia playing a major role. The initial management involves empiric antibiotics until a pathogen is identified. Surgical consult is also suggested, and indications for surgery include heart failure due to valve dysfunction, uncontrolled infection, prevention of embolism, and hemodynamic compromise. Prompt recognition and intervention is crucial in the prevention of mortality in patients with IE leading to mitral perforation and hemodynamic compromise.
感染性心内膜炎（IE）通常由[具体病因未给出]引起，可累及多个心脏结构，导致显著的发病率和死亡率。我们报告一例IE病例，二尖瓣广泛受累，导致穿孔和血流动力学障碍。一名66岁的白种女性因进行性精神状态改变和嗜睡就诊于急诊科。患者及其家属在访谈中否认有静脉药物使用史（IVDU）。体格检查发现呼吸急促、心动过速、嗜睡，右肘前窝有波动感，引流浆液性液体。初步检查发现尿路感染、胸部X线显示双侧斑片状模糊影、低氧性呼吸衰竭、乳酸和心脏标志物升高、白细胞增多，尿毒理学检测显示阿片类药物和苯二氮䓬类药物阳性。她被插管并收入重症监护病房，后来发展为急性呼吸窘迫综合征，需要使用血管升压药。开始使用抗生素，血培养最终培养出对甲氧西林敏感的[具体病菌未给出]。2019冠状病毒病（COVID-19）检测结果为阴性。因感染性休克导致心肌损伤，心脏标志物升高，故咨询了心脏病专家。经胸超声心动图显示二尖瓣前叶有一个大的活动团块。经食管超声心动图进一步评估显示二尖瓣环内侧有一个大的、活动的、中心坏死的赘生物，延伸至前后叶。瓣膜多普勒显示全收缩期逆行射血进入左心房，证实有穿孔。患者被紧急转至一家有心脏胸外科手术能力的中心，对二尖瓣进行手术干预。IE最常见的病因是[具体病因未给出]，在人工瓣膜、先天性心脏病和心内装置患者中发病率最高。然而，大约50%的IE发生在没有任何瓣膜疾病的患者中。其他危险因素包括IVDU、瓣膜疾病和既往心内膜炎病史。IE的临床诊断采用杜克标准，超声心动图和菌血症起主要作用。初始治疗包括经验性使用抗生素，直到确定病原体。也建议进行外科会诊，手术指征包括瓣膜功能障碍导致的心力衰竭、无法控制的感染、预防栓塞和血流动力学障碍。及时识别和干预对于预防IE导致二尖瓣穿孔和血流动力学障碍患者的死亡至关重要。
