Mitral valve pseudoaneurysm – missed acute phase endocarditis case report

    Authors

    Abstract

    **Case report**: 26-year-old patient with a systemic lupus erythematosus diagnosed a year ago was hospitalized because one day temperature without a concomitant increase in inflammatory laboratory parameters. At admission, the transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed pseudoaneurysm of the anterior mitral cusps (**Figure 1**, and **Figure 2**). Blood cultures at admission, as well as those sampled later, were all negative. One year earlier, the patient was hospitalized for febrile pancytopenia and Staphylococcus aureus septicemia. Diagnostics confirmed normal hematopoiesis but revealed systemic lupus erythematosus. Echocardiography performed early during the first hospitalization was normal (**Figure 3**). Antibiotic therapy was initiated. Blood culture test became negative without expected clinical recovery, so corticosteroid therapy was added. After three weeks of treatment, the patient was released home cured. Corticosteroid therapy was terminated after a gradual dose reduction. The patient felt well until the second hospitalization. Endocarditis was not confirmed during the second hospitalization, suggesting the sterile mitral valve pseudoaneurysm. Because of the potential risk for further deformation and mitral valve rupture, surgical valve reparation was suggested and done without complications. FIGURE 1. Transthoracic echocardiography: mitral valve pseudoaneurysm (long axis view). FIGURE 2. Three-dimensional transesophageal echocardiography: mitral valve pseudoaneurysm. FIGURE 3. Transthoracic echocardiography early during *S. aureus* septicemia. **Discussion**: Infectious endocarditis is a challenging disease. Echocardiography is the basic imaging method, especially in the circumstances of the high clinical suspicious based on Duke’s criteria (1). In the case of native valves, the sensitivity of TEE is 90 to 100%, and specificity 90% in the detection of vegetation, perforation or fistula (2). In the detection of paravalvular abscesses, the sensitivity of TEE is 80-90% and of TTE is only 36-50%, or even less for small abscesses (3). In the case of a negative echocardiographic finding and high clinical suspicion of endocarditis, TTE / TEE should be repeated 5-7 days later, in the case of S. aureus infection even earlier (4). A repeated negative study should virtually rule out the diagnosis. This case highlights the importance of two echocardiographic examinations at least seven days apart if there is a doubt about endocarditis, especially in the presence of S. aureus infection as it was the case.

    Keywords

    endocarditis, pseudoaneurysm, echocardiography, lupus erythematosus

    DOI

    https://doi.org/10.15836/ccar2019.55

    Literature

    1. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009 Oct;30(19):2369–413. https://doi.org/10.1093/eurheartj/ehp285
    2. Vieira ML, Grinberg M, Pomerantzeff PM, Andrade JL, Mansur AJ. Repeated echocardiographic examinations of patients with suspected infective endocarditis. Heart. 2004 Sep;90(9):1020–4. https://doi.org/10.1136/hrt.2003.025585
    3. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21;36(44):3075–128. https://doi.org/10.1093/eurheartj/ehv319
    4. Shafran SD. Infective endocarditis and perivalvular abscess: a dangerous duo. CMAJ. 2002 Jul 9;167(1):38–9. https://pubmed.ncbi.nlm.nih.gov/12137076/
    Cardiologia Croatica
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    Mitral valve pseudoaneurysm – missed acute phase endocarditis case report

    Extended Abstract
    Issue3-4
    Published
    Pages55-56
    PDF via DOIhttps://doi.org/10.15836/ccar2019.55
    endocarditis
    pseudoaneurysm
    echocardiography
    lupus erythematosus

    Authors

    Blanka Glavaš Konja*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Vlatka Lukšić ReškovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Irena Ivanac VranešićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Majda Vrkić KirhmajerORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Zvonimir OstojićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Marija ManceORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jelena HucikaUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jurica ŠalkovićUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Joško BulumORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Martina Lovrić BenčićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jadranka Šeparović HanževačkiORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: blanka.glavas@gmail.com

    Abstract

    **Case report**: 26-year-old patient with a systemic lupus erythematosus diagnosed a year ago was hospitalized because one day temperature without a concomitant increase in inflammatory laboratory parameters. At admission, the transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed pseudoaneurysm of the anterior mitral cusps (**Figure 1**, and **Figure 2**). Blood cultures at admission, as well as those sampled later, were all negative. One year earlier, the patient was hospitalized for febrile pancytopenia and Staphylococcus aureus septicemia. Diagnostics confirmed normal hematopoiesis but revealed systemic lupus erythematosus. Echocardiography performed early during the first hospitalization was normal (**Figure 3**). Antibiotic therapy was initiated. Blood culture test became negative without expected clinical recovery, so corticosteroid therapy was added. After three weeks of treatment, the patient was released home cured. Corticosteroid therapy was terminated after a gradual dose reduction. The patient felt well until the second hospitalization. Endocarditis was not confirmed during the second hospitalization, suggesting the sterile mitral valve pseudoaneurysm. Because of the potential risk for further deformation and mitral valve rupture, surgical valve reparation was suggested and done without complications. FIGURE 1. Transthoracic echocardiography: mitral valve pseudoaneurysm (long axis view). FIGURE 2. Three-dimensional transesophageal echocardiography: mitral valve pseudoaneurysm. FIGURE 3. Transthoracic echocardiography early during *S. aureus* septicemia. **Discussion**: Infectious endocarditis is a challenging disease. Echocardiography is the basic imaging method, especially in the circumstances of the high clinical suspicious based on Duke’s criteria (1). In the case of native valves, the sensitivity of TEE is 90 to 100%, and specificity 90% in the detection of vegetation, perforation or fistula (2). In the detection of paravalvular abscesses, the sensitivity of TEE is 80-90% and of TTE is only 36-50%, or even less for small abscesses (3). In the case of a negative echocardiographic finding and high clinical suspicion of endocarditis, TTE / TEE should be repeated 5-7 days later, in the case of S. aureus infection even earlier (4). A repeated negative study should virtually rule out the diagnosis. This case highlights the importance of two echocardiographic examinations at least seven days apart if there is a doubt about endocarditis, especially in the presence of S. aureus infection as it was the case.

    Literature

    1. 1.
      Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009 Oct;30(19):2369–413.DOI
    2. 2.
      Vieira ML, Grinberg M, Pomerantzeff PM, Andrade JL, Mansur AJ. Repeated echocardiographic examinations of patients with suspected infective endocarditis. Heart. 2004 Sep;90(9):1020–4.DOI
    3. 3.
      Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21;36(44):3075–128.DOI
    4. 4.
      Shafran SD. Infective endocarditis and perivalvular abscess: a dangerous duo. CMAJ. 2002 Jul 9;167(1):38–9.PubMed