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Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 222-224

A rare case of infective endocarditis with multiple vegetations and invasion of papillary muscle

Institute of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India

Date of Web Publication12-Dec-2017

Correspondence Address:
Dr. V Blessvin Jino
Post Graduate, Institute of Cardiology, Madras Medical College, Chennai - 03, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_49_17

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Infective endocarditis (IE) is a life threatening infection of cardiac valves leading to high mortality, if it is not recognized earlier and promptly treated. Usually, IE affects single cardiac valve. Angry looking vegetations at multiple sites and vegetations invading the papillary muscles are rare. Such involvement is associated with even higher mortality. Here we present a case of Infective endocarditis with multiple vegetations involving mitral valve, aortic valve and papillary muscle of left ventricle with heart failure who was successfully treated with antibiotics and heart failure drugs and subsequently with double valve replacement. Patient was hemodynamically stable after surgery and is on regular follow-up.

Keywords: Heart failure, infective endocarditis, multiple vegetations, papillary muscle vegetation, transthoracic echocardiography

How to cite this article:
Jino V B, Mary Majella J C, Nageswaran C, Gnanavelu G, Swaminathan N, Venkatesan S. A rare case of infective endocarditis with multiple vegetations and invasion of papillary muscle. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:222-4

How to cite this URL:
Jino V B, Mary Majella J C, Nageswaran C, Gnanavelu G, Swaminathan N, Venkatesan S. A rare case of infective endocarditis with multiple vegetations and invasion of papillary muscle. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2017 [cited 2021 May 9];1:222-4. Available from: https://www.jiaecho.org/text.asp?2017/1/3/222/220539

  Introduction Top

Infective endocarditis (IE) is a life-threatening and challenging medical condition with high mortality rate (10%–30% in-hospital mortality). In spite of the recent advances in the diagnostic methods and antibiotic therapy, the mortality remains higher. Transthoracic echocardiography (TTE) is recommended as the first-line imaging modality in a case of suspected IE, and it plays a key role in the follow-up of these patients. Surgery is required in almost 50% of the patients with IE because of the complications. Heart failure (HF) is the most common complication of IE, and it is the most frequent indication for surgery in IE. HF is mainly caused by new or worsening severe aortic or mitral regurgitation (MR). Vegetations are the hallmark of IE. IE commonly affects a single cardiac valve. IE affecting two valves is uncommon, and the involvement of more than two valves is extremely rare. The papillary muscles are rarely involved in IE.

  Clinical Presentation Top

A 24-year-old male was admitted in our hospital with the history of high-grade fever for 2 weeks. He had no previous history of rheumatic heart disease or intravenous drug abuse. His retroviral status was nonreactive. He was treated elsewhere with antibiotics for 2 weeks. In a view of persistent fever, he was referred to our hospital for further management. On evaluation in our hospital, his blood culture was negative. TTE showed rheumatic heart disease with thickened anterior and posterior mitral leaflets and restricted posterior leaflet mobility and diastolic doming of the anterior mitral leaflet. There were multiple vegetations attached to the aortic valve, mitral valve, and posteromedial papillary muscle of the Left ventricle (LV). The aortic valve had 8 mm × 18 mm sized vegetation over its noncoronary cusp and 5 mm × 8 mm vegetation over the right coronary cusp on the LV side [Figure 2]. Anterior mitral leaflet on its LV side had 9 mm × 12 mm sized vegetation [Figure 1], and the posteromedial papillary muscle of the LV had 8 mm × 19 mm sized vegetation [Figure 3]. He had severe Mitral regurgitation and severe aortic regurgitation. His ejection fraction was 48%. He was treated initially with intravenous antibiotics (injection ceftriaxone 2 g/day and gentamicin 3 mg/kg/day) and antifailure measures for 4 weeks. During antibiotic therapy, the patient developed embolic stroke, and he was managed conservatively. The patient did not respond well to antibiotics. As the symptoms worsened to NYHA IV and the ejection fraction deteriorated to 38%, the double valve replacement was done. The histopathological examination of the specimen (both aortic and mitral valves) revealed vegetation with fibrin, platelets, and neutrophilic infiltration with underlying valvular inflammatory reaction. The patient was hemodynamically stable after the valve replacement. Follow-up echocardiography showed no recurrence of IE.
Figure 1: Anterior mitral leaflet with a 9 mm × 12 mm sized vegetation

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Figure 2: Aortic valve with an 8 mm × 18 mm sized vegetation over noncoronary cusp and 5 mm × 8 mm vegetation over the right coronary cusp

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Figure 3: Posteromedial papillary muscle of the left ventricular with an 8 mm × 19 mm sized vegetation

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  Discussion Top

IE is one of the worst diseases affecting the cardiac valves, and its global incidence ranges between 1.5 and 11.6 cases per 100,000 people.[1] The diagnosis of IE is based on the clinical symptoms, microbiologic findings (blood culture), and imaging techniques, mainly echocardiography. TTE is the initial imaging method of choice for native valve endocarditis. The sensitivity of TTE for diagnosing vegetations in native and prosthetic valve IE is 70% and 50%, respectively, and for transesophageal echocardiography (TOE), it is 96% and 92%, respectively.[2]

Vegetations are the hallmark of IE. Vegetations are usually situated over the atrial side of the atrioventricular valves and over the ventricular side of the aortic and pulmonary valves. IE mostly involves a single cardiac valve. Multivalvular involvement is less frequent, and it occurs in 15% of all IE cases.[3] When IE involves both left-sided valves, the primary involvement is usually over the aortic valve and the mitral involvement occurs secondarily. Multivalvular IE is usually associated with more clinical complications (HF 65%, acute kidney injury 44%, and systemic embolization 24%).[4] The aortic valve IE leads to more HF than the mitral valve IE. The most common causative organism in multivalvular IE is Staphylococcus. However, some studies report viridans streptococci as the most common causative organism in multivalvular IE.[5],[6]

The papillary muscles are rarely involved in IE, and if involved, they are usually associated with papillary muscle rupture and severe MR. The papillary muscle vegetations have a higher risk of systemic embolization. TOE is a better imaging modality than TTE in detecting papillary muscle endocarditis. Multivalvular IE patients most often need surgery. The surgical therapy is superior to medical treatment in the multivalvular IE patients. Early surgical intervention before abscess formation is very important for the survival of these patients.[6] The surgical treatment during the active phase of endocarditis is associated with significantly higher risk of perioperative complications. However, during the active phase of IE (while on antibiotics), surgery may be considered with the aim to avoid the worsening HF, irreversible structural damage and to prevent the systemic embolization. Surgery includes the radical debridement of all the infected material and reconstruction of the valvular apparatus. Patients treated with surgery have acceptable early and late mortality and very good postoperative functional status.

  Conclusion Top

This case is presented for the rarity of papillary muscle involvement in IE. Patients, when timely treated, improve with surgery even during the active phase of infection, and it is superior to medical therapy alone, as seen in this case.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bin Abdulhak AA, Baddour LM, Erwin PJ, Hoen B, Chu VH, Mensah GA, et al. Global and regional burden of infective endocarditis, 1990-2010: A systematic review of the literature. Glob Heart 2014;9:131-43.  Back to cited text no. 1
Habib G, Badano L, Tribouilloy C, Vilacosta I, Zamorano JL, Galderisi M, et al. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr 2010;11:202-19.  Back to cited text no. 2
Selton-Suty C, Doco-Lecompte T, Bernard Y, Duval X, Letranchant L, Delahaye F, et al. Clinical and microbiologic features of multivalvular endocarditis. Curr Infect Dis Rep 2010;12:237-43.  Back to cited text no. 3
López J, Revilla A, Vilacosta I, Sevilla T, García H, Gómez I, et al. Multiple-valve infective endocarditis: Clinical, microbiologic, echocardiographic, and prognostic profile. Medicine (Baltimore) 2011;90:231-6.  Back to cited text no. 4
Yao F, Han L, Xu ZY, Zou LJ, Huang SD, Wang ZN, et al. Surgical treatment of multivalvular endocarditis: Twenty-one-year single center experience. J Thorac Cardiovasc Surg 2009;137:1475-80.  Back to cited text no. 5
Mihaljevic T, Byrne JG, Cohn LH, Aranki SF. Long-term results of multivalve surgery for infective multivalve endocarditis. Eur J Cardiothorac Surg 2001;20:842-6.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]


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