Anesth Analg 2006;103:307-308
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000226168.79777.8d
CARDIOVASCULAR ANESTHESIA
An Unusual Case of Endocarditis
Roman M. Sniecinski, MD,
Gregory C. Sund, MD, and
James G. Ramsay, MD
From the Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.
Address correspondence and reprint requests to Roman M. Sniecinski, MD, Emory University Hospital; Department of Anesthesiology, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to Roman.Sniecinski{at}emoryhealthcare.org.
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Introduction
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A 54-yr-old woman from the United States Virgin Islands presented to an outside hospital with the chief complaint of shortness of breath and a heart murmur. Her medical history was significant for mild chronic obstructive pulmonary disease and a distant history of colon cancer, status post-resection 15 yr previously. Transesophageal echocardiography (TEE) obtained at that time diagnosed her with a "large mitral valve leaflet myxoma," causing severe mitral regurgitation. Other notable findings were mild aortic insufficiency and moderate tricuspid regurgitation. Both right and left ventricles had normal function, with an ejection fraction >55%. She was referred to our institution for mitral valve surgery. Her preoperative cardiac catheterization confirmed severe mitral regurgitation, thickened leaflets, and a left atrial myxoma. She was taken to the surgical suite, where intraoperative TEE obtained the images shown in Figures 1 and 2 (please see video loop available at www.anesthesia-analgesia.org). Surgical inspection of the mitral valve revealed inflamed tissue extending from the leaflets and outside the annulus to the left atrium. Because of the friability of the leaflets and the extent of their destruction, the valve was deemed nonrepairable and a #32 Mosaic bioprosthetic valve was implanted. Extensive work-up by two pathology departments showed substantial destruction of the entire valvular architecture with foci of T-cells and histiocytes. There was no evidence of lymphoma or any type of neoplasm, and noninfectious inflammation such as rheumatoid arthritis, rheumatic disease, or Wegener’s granulomatosis was also excluded. Although no positive cultures were ever obtained, the final pathological diagnosis was a chronic inflammation caused by an atypical infectious endocarditis.
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Figure 1. Mid-esophageal 2-chamber view. Note the arrows pointing to thickened valve leaflets and inflammatory tissue extending into the left atrium.
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Figure 2. Mid-esophageal 4-chamber view with color compare. Note the arrow pointing to thickening of the chordae and entire subvalvular apparatus. The color flow Doppler shows severe mitral regurgitation.
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This was an unusual case of endocarditis, in that the patient did not have any predisposing factors such as IV drug use, immunodeficiency, or prior valve replacement. Her clinical presentation was very nonspecific, with dyspnea and a heart murmur that may or may not have been preexisting. Standard cultures and stains were negative for microorganisms, pointing toward a more unusual pathogen such as mycoplasma, Brucella, or one of the HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenalla, and Kingella). These pathogens account for 3%–10% of native-valve endocarditis cases in the age group of 16- to 60-yr old (1). Perhaps the most unusual aspect of this case, however, is the TEE images themselves. Vegetations, typically on the upstream side of a regurgitant valve, are the hallmark for infective endocarditis and are a major criterion for its diagnosis (2). What appeared in this patient was more of an inflammatory "coating," covering the subvalvular apparatus, leaflets, and extending into the left atrium. The atypical appearance led to the misdiagnosis of a tumor on both prior TEE and cardiac catheterization. This case illustrates that endocarditis can take on many appearances.
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Video Clip:
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This is a mid-esophageal 2 chamber view showing the thickened leaflets and inflammatory tissue extending into the left atrium.
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Footnotes
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This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
Accepted for publication April 10, 2006.
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REFERENCES
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- Mylonakis E, Calderwood SB. Medical progress: infective endocarditis in adults. N Engl J Med 2001; 345:1318–30.[Free Full Text]
- Durak DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med 1994; 96:200–9.[ISI][Medline]
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Introduction
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