A Classic Case of Mitral Valve Endocarditis

May 4, 2009
Marc L. Baker, MD, PhD

A young woman presented with fevers, chills and a holosystolic murmur that radiated to her axilla, and became louder with handgrip maneuvers.

Presentation and evaluation

A young woman presented with fevers, chills and a holosystolic murmur that radiated to her axilla, and became louder with handgrip maneuvers. Historically she has a primum atrial septal defect (ASD), a cleft mitral valve, and ASD closure with mitral valuloplasty. She had linear splinter hemorrhages under her nail beds (Figure 1 white arrows). She had non-tender, erythematous nodular palmar Janeway lesions (Figure 2 white arrows), and small septic distal ankle and digital emboli (Figures 3a, 3b white arrows). The patient was evaluated by the ophthalmology consult team, who noted multiple Roth spots on the patient's left eye.

(Figure 1)

(Figure 2)

(Figure 3a)

(Figure 3b)

Diagnosis

Echocardiography reveals a tissue-density mass on the left atrial side of the mitral annulus. There is one mobile mass that almost prolapses through the mitral valve (Figure 4 white arrow). The site of mitral regurgitation is here (Figure 5 white arrow), which suggests endocarditis. Blood cultures were positive for methicillin sensitive staph aureus. This study confirmed a diagnosis of endocarditis that was already made on clinical grounds.

(Figure 4)

(Figure 5)

Patient management and outcome

She completed 6 weeks of IV Nafcillin without adverse effects, as an outpatient. Currently, she has resumed her exercise regimen without limitation. A repeat echocardiogram reveals the mitral valve is abnormal and has an atypical pattern of doming. Two jets of mitral regurgitation are appreciated. One jet emanates from the coaptation point of anterior and posterior leaflet. There also appears to be a tear in the anterior leaflet where another jet originates. The degree of mitral regurgitation is now moderate to severe. Surveillance echocardiography will be performed, and although currently asymptomatic, surgical options are being discussed.

Discussion

The incidence of Infective Endocarditis in adults ranged from 5 to 7 cases per 100 000 person-years.1 This incidence has remained stable during the past 4 decades and is similar to that reported in other studies.2,3 In developed countries, the frequency of Rheumatic Heart Disease has declined, and mitral valve prolapse is now the most common underlying condition in patients with endocarditis.4 The risk of endocarditis in congenital heart disease was reviewed and specific recommendations for congenital heart disease and antibiotic prophylaxis have been modified recently.5 Prophylaxis is specifically recommended for the following conditions: 1) Unrepaired cyanotic CHD, including palliative shunts and conduits. 2) Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure. 3) Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization). Congenital Heart Disease requires surveillance and clinical evaluation as the risk of endocarditis may be higher than that of the general population. The classic physical exam findings in this case identified the disease process, but the echocardiography surveillance may aid in surgical treatment for the future.

Reference List

1) Griffin MR, Wilson WR, Edwards WD, O'Fallon WM, Kurland LT. Infective endocarditis. Olmsted County, Minnesota, 1950 through 1981. JAMA: The Journal of the American Medical Association 1985 September 6;254(9):1199-202.

2) Hoen B, Alla F, Selton-Suty C, Beguinot I, Bouvet A, Briancon S, Casalta JP, Danchin N, Delahaye F, Etienne J, Le Moing V, Leport C, Mainardi JL, Ruimy R, Vandenesch F, for the Association pour l'Etude et la Prevention de l'Endocardite Infectieuse Study Group. Changing Profile of Infective Endocarditis: Results of a 1-Year Survey in France. JAMA: The Journal of the American Medical Association 2002 July 3;288(1):75-81.

3) Delahaye F, Goulet V, Lacassen F, Ecochard R, Selton-Suty C, Hoen B, Etienne J, Briancon S, Leport C. Characteristics of infective endocarditis in France in 1991: A 1-year survey. Eur Heart J 1995 March 1;16(3):394-401.

4) Tleyjeh IM, Steckelberg JM, Murad HS, Anavekar NS, Ghomrawi HMK, Mirzoyev Z, Moustafa SE, Hoskin TL, Mandrekar JN, Wilson WR, Baddour LM. Temporal Trends in Infective Endocarditis: A Population-Based Study in Olmsted County, Minnesota. JAMA: The Journal of the American Medical Association 2005 June 22;293(24):3022-8.

5) Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT, The Council on Scientific Affairs of the American Dental Association has approved the guideline as it relates to dentistry. Prevention of Infective Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007 October 9;116(15):1736-54.