Fístula aorta-ventrículo direito: uma complicação inesperada da endocardite bacteriana

Abstract

A 22-year-old white man, admitted with a dry cough complaint, dyspnea to effort, palpitations and daily fever, with a two-month evolution. Patient of congenital cardiopathy and cataract. His mother had German measles in the second month of pregnancy. BP = 160/90 mmHg in upper limbs, there were no palpable pulses in lower limbs. Systolic impulse verified in the 5 th left paraesternal intercostal space, where a tremor irradiated until the 2 nd right paraesternal intercostal space. A rude mesotelesystolic murmur audible in that region, irradiating to cervical, subclavicular and interscapular regions. The diagnostic hypothesis was infectious endocarditis, aortic valvar stenosis and coarctation of the aorta. At electrocardiogram, sinus rhythm and left ventricular overload; the thoracic radiography was normal. At blood count, anemia and leukocytosis were found. He was empirically treated with ceftriaxone 3g day.At hemoculture, Streptococcus viridans was sensitive to the antibiotic used.With the treatment, he was afebrile and without complaints. There was a sudden settlement of dyspnea, diaphoresis and cutaneous-mucous paleness. Crepitations were audible in the bases. A new continuous murmur in precordium was diagnosed. Echocardiogram demonstrated an aorta-right ventricle fistula, bicuspid aortic valve with suggestive images of vegetations and coarctation of the aorta (fig. 1). The patient died while waiting for emergency heart surgery.Necropsy findings was aorta-right ventricle fistula, besides confirming echocardiogram findings ( fig. 2 and 3) .Endocarditis has been currently, especially in developing countries, where rheumatic valvar disease has high prevalence. Besides, it is a feasible complication from congenital cardiopathies 1-3 .A rude murmur in the 2 nd right intercostal paraesternal space, with irradiations to cervical, left subclavicular and interscapular regions, makes us suspect aortic stenosis, associated to a possible coarctation of the aorta, which was clinically confirmed by the absence of pulses in lower