Case report
A 51-year-old healthy male patient with no relevant medical history was
admitted to the emergency room with a one-week history of fever having a
mild response to paracetamol, headaches, myalgia and neck stiffness. He
denied coughing, dyspnea or chest pain. During physical examination, his
heart rate was 145 bpm and blood pressure was 90/60 mmHg.
Cardiopulmonary auscultation was rhythmic and showed no abnormalities.
Laboratory results on admission showed a leukocyte count of 22,860/μL
with neutrophilia (84.9%) and thrombocytopenia (49,000/μL). Acute
kidney injury was also shown by a creatinine of 1.4 mg/dL and
hyponatremia (126 mmol/L). Bilirrubin was 1.4 mg/dL. Arterial blood
gases showed hypoxemia and hypocapnia with secondary respiratory
alkalosis. Acute-phase reactants were elevated with a C-reactive protein
of 23.4 mg/dL (0.0 – 0.5) and a procalcitonin of 5.26 μg/L (0.00 –
0.50). The chest X-Ray showed no significant findings. Blood, urine
cultures and a nasal swab were drawn, which were all positive for
Methicillin-sensitive Staphylococcus aureus (MSSA).
The patient was directly admitted into the intensive care unit with the
diagnosis of septic shock. Broad-spectrum antibiotic therapy was started
with Meropenem and Vancomycin. Blood cultures were drawn again the next
day, being still positive for MSSA. The patient required vasoactive
drugs for 48 hours. After 72 hours, the patient was stable and
transferred to the cardiology ward. Antibiotic therapy was then changed
to Meropenem and Cloxacillin.
The transthoracic echocardiogram (TTE) showed no abnormalities.
Transesophageal echocardiogram (TEE) was not performed due to the
patient’s rejection of this procedure. On the 6th day
of hospitalization, the patient asked to be discharged against medical
advice. The antibiotic therapy was discontinued.
Two days later, the patient returned to the emergency department with
persistent fever and signs of right heart failure in physical
examination. The patient was then readmitted and antibiotic therapy with
Daptomycin and Cloxacillin was started. The chest X-Ray showed bilateral
mild pleural effusions and images suggesting bilateral multilobar
pneumonic foci similar to pulmonary septic embolisms (Figure_1).
A new TTE was performed on suspicion of right heart IE, but showed no
abnormal findings. TEE was then performed showing nodular images on the
PV suggestive of large vegetations (Figure_2) causing substantial valve
destructuration and severe pulmonary regurgitation (IV/IV) (Figure_3).
Tricuspid regurgitation was mild without suggestive signs of IE. The
rest of the study was normal.
The case was accepted for urgent surgery. Among the different techniques
for the reconstruction of the pulmonary valve have been described, a
biologic valve replacement according to Kogon’s
technique4 was the chosen procedure. On the surgical
field, a severely unstructured PV with large vegetations anchored to the
anterior and right leaflets was identified (Figure_4). There was also
an infra-annular abscess, not visualized in the TEE, rightly below the
left leaflet that spread through the posterior infundibular wall with no
signs of perforation.
Once the vegetations were excised, the abscess was also drained, cleaned
and finally closed with a bovine pericardial patch (Figure_5). The
pulmonary valve was replaced with a bioprosthetic valve. The main
pulmonary artery and right ventricular infundibulum were reconstructed
with another bovine pericardial patch (Figure_6).
The intraoperative TEE showed no paravalvular leaks with a normal
functioning prosthesis. The patient experienced an uncomplicated
postoperative period, being extubated immediately after surgery and
transferred to the ward 48 hours later.
A postoperative computed tomography scan showed images suggestive of
bilateral pulmonary septic embolisms and thromboembolisms with infarcts
(Figure_7) The microbiological test of the valve confirmed IE caused byStaphylococcus aureus .
The patient was discharged once the antibiotic therapy was completed and
remains asymptomatic.