A 35 year old woman with a long history of intravenous drug abuse presented to a local hospital with severe anaemia, fever, raised markers of inflammation, and positive blood cultures for Staphylococcus aureus. She responded to treatment with antibiotics with improvement in her symptoms and markers of inflammation. Four weeks later a "routine" echocardiogram showed a rupture of her left ventricular apex and a large pseudoaneurysm. There had been no deterioration in her symptoms or haemodynamic status to herald this new development. It was successfully repaired surgically and the patient made a good recovery. (Heart 2001;85:e4) Keywords: ventricular rupture; pseudoaneurysm; staphylococcal septicaemia Cardiac rupture and pseudoaneurysm of the left ventricular free wall is a well recognised complication of myocardial infarction, cardiac trauma or cardiac surgery.1 2 There are a few reported associations with endocarditis, septicaemia or tumour infiltration.3-6 These reported cases are all associated with a sudden or progressive haemodynamic deterioration. We report a case of cardiac rupture and pseudoaneurysm of the left ventricular free wall found on "routine" echocardiography in a patient with Staphylococcus aureus septicaemia.
Case reportA 35 year old female intravenous drug abuser was referred to a local hospital with a three week history of malaise, lethargy, and weight loss. She had lost 10 kg in three weeks and complained of left sided pleuritic chest pains.She had a long history of intravenous drug misuse and had been on a methadone withdrawal programme for two months, although she admitted to the concomitant use of heroine. In 1992 and 1997 she was admitted to the same hospital with a left proximal deep vein thrombosis and right groin abscess respectively caused by injecting heroin into her femoral vein. A systolic murmur had been heard and an echocardiogram booked, but she had defaulted.On examination she looked ill and had a low grade pyrexia. She had a tachycardia of 100 beats/min but was normotensive. There were no cutaneous stigmata of endocarditis and the only positive finding was a systolic murmur suggestive of mitral regurgitation.Investigations revealed a microcytic anaemia with a haemoglobin of 3.5 mmol/l (5.7 g/d1) and a white cell count of 10.7 × 10 9 /l. Inflammatory markers were raised (C reactive protein 130 mg/l and erythrocyte sedimentation rate 54 mm/hour), and two sets of blood cultures grew S aureus. Her chest x ray was normal. The ECG showed non-specific T wave inversion aVecting the inferiolateral leads. Her echocardiogram revealed normal left ventricular systolic function and a left ventricular band near the apex. There was mild mitral and tricuspid regurgitation but no vegetations were seen. The aortic valve was normal. A small pericardial eVusion was noted. A diagnosis of bacterial endocarditis was made and she was treated with appropriate antibiotics (flucloxacillin and gentamicin) and given a transfusion of 4 units of blood. Her temperature settled and markers of infla...
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