Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

A 46 year-old female with past medical history of congenital aortic stenosis status post bovine bioprosthetic valve replacement and an ascending aortic aneurysm repair 13 years prior to presentation presented with fatigue and generalized weakness. The patient also had a history of non-obstructive coronary artery disease, hypertension, and HFpEF. She recently was diagnosed with infectious mononucleosis 3 weeks prior. In the 1 month prior to her index presentation she had two prior admissions for respiratory symptoms. On physical exam, the patient had a 4/6 holosystolic murmur. Her laboratory markers revealed a profound leukocytosis, mild anemia, a mild troponinemia, hypokalemia, and hyponatremia. Blood cultures revealed staphylococcus epidermidis. Due to inconclusive TTE findings and recurrent presentations with non-specific symptoms, a transesophageal echocardiogram (TEE) was performed. TEE revealed a 5 mm mobile echodensity on the bioprosthetic valve suggestive of a vegetation along with prosthetic valve dehiscence. The TEE also noted abscess formation of the aortic annulus and a fistula between the sinus of valsalva and the left atrium. There was severe mitral regurgitation with perforation of the anterior mitral valve leaflet. Given the extensive endocarditis the patient was to be transferred to a tertiary care facility for cardiothoracic surgery evaluation. In the interim, the patient developed multiple arrhythmias and conduction disease due to the aortic root abscess and infection burden. Throughout her admission she clinically deteriorated and required vasopressor support for mixed shock. Sadly, our patient sustained a cardiac arrest and despite our best efforts she passed away while awaiting transfer. Although infective endocarditis is typically diagnosed quickly with imaging and managed medically, it is important to recognize the downstream effects of this condition, especially in patients with prior prosthetic valves who are at a higher risk of complications and can have an indolent presentation. Despite having severe valvular disease and endocarditis our patient did not present with classical symptoms of decompensated heart failure at presentation, but rather more non-specific symptoms. Conduction abnormalities are typically suggestive of an aortic root abscess and carry an increased mortality risk along with the need for urgent cardiac surgery. As internists, it is crucial to be vigilant of patients with prior valvular surgeries and procedures who are at risk of prosthetic valve infections and to obtain appropriate imaging.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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