The Unseen Culprit: Occult Cardiac Abscess Presenting as Recurrent MRSA Bacteremia

Document Type

Conference Proceeding

Publication Date

4-7-2026

Publication Title

Journal of the American College of Cardiology

Abstract

BACKGROUND We present a case of a 56-year-old male who experienced recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia despite appropriate antimicrobial therapy and source control. Advanced imaging ultimately revealed an occult cardiac abscess with left ventricular pseudoaneurysm, necessitating surgical intervention. CASE A 56-year-old male with poorly controlled T2DM, first presented in October with MRSA bacteremia attributed to a diabetic foot ulcer, treated with amputation and 6 weeks of vancomycin. TEE was negative for vegetations. Six weeks later, he developed sternoclavicular septic arthritis with MRSA bacteremia again with negative TEE. He underwent joint resection and completed 6 weeks of daptomycin, followed by oral doxycycline, with initial blood culture clearance. However, recurrent MRSA bacteremia occurred in February, 4 months after initial diagnosis, complicated by brain and psoas abscesses and vertebral osteomyelitis. DECISION-MAKING Recurrent bacteremia despite appropriate antibiotics and source control (amputation, joint resection) prompted suspicion of an occult focus. Negative TEEs initially suggested noncardiac sources, but persistent and widespread infections (brain, psoas, vertebral) raised concern for septic emboli and necessitated advanced imaging. Cardiac CTA and PET confirmed a cardiac source: a mitral annular/left ventricular abscess with pseudoaneurysm. Surgical intervention with unroofing, debridement, mitral valve replacement, and pericardial patch repair, achieved definitive source control. Key teaching points include the limitations of TEE in detecting nonvalvular cardiac infections and the value of multimodality imaging (CTA, PET) in recurrent bacteremia. CONCLUSION The patient’s recurrent MRSA bacteremia was resolved through identification and surgical management of an occult cardiac abscess, with no further bacteremia noted after surgery and a final course of ceftaroline and linezolid therapy. Comprehensive multimodality cardiac evaluation is critical in persistent MRSA infections even in the setting of negative TEE, highlighting the limitations of the latter in this case.

Volume

87

Issue

13 Suppl

First Page

A1755

Comments

American College of Cardiology 75th Annual Scientific Session & Expo, March 28-30, 2026, New Orleans, LA

Last Page

A1755

DOI

10.1016/j.jacc.2026.02.4392

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