Aortic valve endocarditis by a rare infectious agent in a patient with a rare congenital mitral valve abnormality

Aortic valve endocarditis by a rare infectious agent in a patient with a rare congenital mitral valve abnormality Jo~ ao R. Agostinho *, Rui Pla´cido, Ana G. Almeida , and Fausto J. Pinto Cardiology Department, Hospital de Santa Maria/CHULN, CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Portugal, Av. Prof. Egas Moniz, Lisbon 1649-035, Portugal Received 3 March 2019; first decision 20 May 2019; accepted 17 September 2019 Case description A 66-year-old woman with a past medical history of high blood pressure, Type 2 diabetes mellitus and no clinical evidence of immunocompromise, presented to the emergency room with fever and acute pulmonary oedema. The patient had presented low-grade fever and anorexia in the previous 3 weeks. Transthoracic echocardiography showed severe aortic regurgitation related to the presence of large aortic vegetations affecting all cusps. Despite the stabilization of the patient after anti-congestive and vasodilator therapy, urgent surgery was considered given high embolic risk. Blood cultures were positive for penicillin-sensitive Leuconostoc mesenteroides. Transoesophageal echocardiographic examination confirmed the presence of large vegetations attached to the aortic valve cusps with friable appearance and great mobility, prolapsing to the left ventricular outflow tract (Figure 1). It also revealed a double-orifice mitral valve, with a presence of a central bridge connecting the two leaflets (complete bridge type) and dividing the valve into two adequate orifices (medial and lateral) causing neither significant stenosis nor significant regurgitant associated jets (Figures 1and 2). The patient underwent aortic valve replacement and a biological prothesis was implanted. With these images, the authors describe and illustrate a normally functioning double-orifice mitral valve associated with L. mesenteroides aortic valve infection an infrequent agent in humans and an extremely rare cause of endocarditis. Figure 1 Transgastric views showing the presence of multiple vegetations and severe aortic regurgitation. Figure 2 Double orifice mitral valve 3D reconstruction. * Corresponding author. Tel: þ351 914 651 723, Email: joaoragost[email protected] Handling Editor: Timothy C. Tan Peer-reviewers: Pankaj Garg, Richard Alexander Brown, and Christian Jøns V CThe Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] European Heart Journal - Case Reports IMAGES IN CARDIOLOGY doi:10.1093/ehjcr/ytz175 Cardiac imaging Downloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz175/5621352 by guest on 12 November 2019 . . . . . . . . . . . . . . . . . . . Supplementary material Supplementary material is available at European Heart Journal - Case Reports online. Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: none declared. 2J.R. Agostinho et al. Downloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz175/5621352 by guest on 12 November 2019