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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 158-159

Mitral valve leaflet abscess: A rare complication of infective endocarditis


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Science and Research, Bengaluru, Karnataka, India

Date of Web Publication28-Aug-2017

Correspondence Address:
Abhishek Rathore
35, KSRTC Layout, JP Nagar, 2nd Phase, Bengaluru - 560 078, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_40_17

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  Abstract 


Infective endocarditis is an infection of the endocardium of heart and its great vessels. Infective endocarditis if complicated by abscess may lead to severe valvular insufficiency and intractable heart failure. Leaflet abscess although is a very rare complication, but if occurs, leads to increased morbidity and mortality. We report a case of 28-year-old female who had severe mitral valve regurgitation with mitral leaflet abscess confirmed by transesophageal echocardiography. She developed cardiogenic shock, multiple organ dysfunction syndrome with anemia, leukocytosis, thrombocytopenia, liver dysfunction, acute renal failure, and splenic abscess. Due to these multiple comorbid conditions, it could be a very high-risk surgery. Hence, she was managed with medical therapy and responded well.

Keywords: Infective endocarditis, mitral valve abscess, transesophageal echocardiography


How to cite this article:
Rathore A, Prabhavathi B, Manjunath C N. Mitral valve leaflet abscess: A rare complication of infective endocarditis. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:158-9

How to cite this URL:
Rathore A, Prabhavathi B, Manjunath C N. Mitral valve leaflet abscess: A rare complication of infective endocarditis. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2017 [cited 2020 Sep 30];1:158-9. Available from: http://www.jiaecho.org/text.asp?2017/1/2/158/213676




  Introduction Top


Infective endocarditis is microbial infection of intact or degenerated cardiac valves, endocardium of the heart, and great vessels. Naive mitral valve abscess is a very rare condition among cardiovascular infections. There are very few case reports of abscess of valve leaflet. We report a case of infective endocarditis complicated by mitral valve leaflet abscess which was managed conservatively with medical therapy only.


  Case Report Top


A 28-year-old female presented with dyspnea, fatigue (New York Heart Association III) for 5 months, orthopnea for 1 month, high-grade fever for 20 days, and pedal edema for 3 days. There was no history of cardiac illness in the past. On physical examination, she had pallor, Grade II clubbing, icterus, raised jugular venous pressure, and pedal edema. She was hemodynamically unstable with blood pressure of 76/60 mmHg on presentation. On cardiovascular examination, she had pansystolic murmur of Grade III at mitral area radiating to the axilla. She also had bilateral crackles on respiratory system examination. She had mild splenomegaly with splenic abscesses on ultrasonography. On investigation, she had microcytic hypochromic anemia, leukocytosis, thrombocytopenia, renal failure, and liver dysfunction [Table 1]. On electrocardiogram, sinus tachycardia was present. Blood cultures were sterile. Transthoracic echocardiogram revealed 1–1.6 cm size vegetation with small cavitary lesion on anterior mitral leaflet leading to severe mitral regurgitation [Figure 1]. Left atrium and left ventricle were dilated with impaired systolic function of the left ventricle. On day 2 of presentation, transesophageal echocardiogram was performed which revealed two echolucent ring-like cavity on the anterior mitral leaflet which confirmed the diagnosis of mitral valve leaflet abscess [Figure 2]. Surgery was not considered in view of multiple comorbid conditions which could be a very high risk to her. She was managed with inotropic agents for 6 days, intravenous penicillin, and trimethoprim-sulfamethoxazole for 4 weeks by which she responded well. Her white blood cell counts, liver functions, and renal functions also became normal and he was discharged after 4 weeks.
Table 1: Patient profile

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Figure 1: Transthoracic echocardiogram depicting small cavitary lesion (white arrow) on the anterior mitral leaflet. (a) Parasternal long axis view. (b) Apical four chamber view

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Figure 2: Transesophageal echocardiogram confirming two abscesses (while arrows) on the anterior mitral leaflet. (a) Mid-esophageal four-chamber view. (b) Zoomed view of the anterior mitral leaflet

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  Discussion Top


Echocardiography is an integral part of the assessment of patients with infective endocarditis. It is used to confirm the diagnosis, associated complications, and to monitor response to antibiotic therapy. Complications of infective endocarditis such as abscess, fistula, and false aneurysm can be easily missed on transthoracic echocardiography, but for more complete assessment, transesophageal echocardiography (TEE) is recommended. TEE has higher frequency imaging, greatly enhancing spatial resolution, and has higher sensitivity and specificity than TTE. TEE can characterize vegetation with a resolution size of approaching 2–3 mm, with sensitivity in the range of 90%–100% and specificity exceeding 90%. Infective endocarditis must be differentiated from nonbacterial thrombotic endocarditis, cardiac tumors, systemic lupus erythematosus, and Lambl's excrescences.

There are many complications of infective endocarditis including aortic root abscess, but an abscess of the mitral valve is very rare.[1],[2],[3],[4] To the best of our knowledge, there are only four cases reported with mitral valve leaflet abscess till now. Due to the rarity of mitral valve leaflet abscess, its true incidence is not known. The prognosis of mitral valve leaflet complicating infective endocarditis is very poor and requires urgent surgery. As the present case had multiple comorbidities including thrombocytopenia, acute renal failure, liver dysfunction, splenic abscess, and marked leukocytosis, surgery could not be possible. However, the patient responded well to intravenous antibiotic therapy and other supportive measures and discharged in stable state.


  Conclusion Top


Infective endocarditis complicated by mitral valve leaflet abscess leads to high morbidity and mortality. TEE should be part of routine evaluation in patients with poor medical conditions including cardiogenic shock to rule out rare but serious complications of infective endocarditis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumbasar SD, Aslan SM, Erol C, Tekeli ME. A case of infective endocarditis complicated with anterior mitral valve leaflet abscess. Eur Heart J 1997;18:1194-5.  Back to cited text no. 1
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2.
Massey WM, Samdarshi TE, Nanda NC, Sanyal RS, Pinheiro L, Jain H, et al. Serial documentation of changes in a mitral valve vegetation progressing to abscess rupture and fistula formation by transesophageal echocardiography. Am Heart J 1992;124:241-8.  Back to cited text no. 2
[PUBMED]    
3.
Saxena P, Boyt A, Newman MA. Mitral valve leaflet abscess complicating infective endocarditis. Heart Lung Circ 2009;18:161-2.  Back to cited text no. 3
[PUBMED]    
4.
Jotkar SK, Harshe GG, Chavan VB. Infective endocarditis complicated with anterior mitral leaflet abscess: A case report. J Cardiovasc Echogr 2014;24:92-4.  Back to cited text no. 4
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