An “aubergine” in the heart: huge native mitral valve endocarditis caused by Streptococcus agalactiae

Abstract

A 52-year-old woman presented to the emergency department (ED) of the ARNAS Civico, Di Cristina, Benfratelli, Palermo (Italy) in January, suffering from fluctuating fever for 3 days, up to 39°C, associated with dyspnea/orthopnea and headache followed by vertigo and left hemiplegia. A cranial computed tomography without contrast, performed in the ED, showed focal hypodensity in the putamen of the right hemisphere; ECG showed sinus tachycardia and a posterior-anterior chest X-ray study showed mild signs of pulmonary vasculature congestion. For this reason, the patient was admitted to the internal medicine department with a diagnosis of ischemic stroke and fever.Physical examination on admission revealed fever (temperature 38.6°C), tachypnea at rest (32 breaths/min), oxygen saturation of pulse oximetry measurement 83%, blood pressure 120/65 mmHg, pulse rate 110 beats/min, no lower extremity edema or jugular venous distention. Chest auscultation revealed bilateral pulmonary crackles. Cardiac auscultation documented a grade 4/6 pansystolic murmur at the mitral valve area radiated to the left anterior axillary line; for this reason, on the second day of admission, bedside transthoracic echocardiogram (TTE) was performed.The TEE revealed a giant (4.06 cm maximum diameter), pedunculated, and highly mobile vegetation attached to the atrial surface of the posterior mitral leaflet, prolapsing into the left ventricle during the ventricular diastolic phase and into the left atrium during ventricular systole phase (Fig.

Group B Streptococcus ( Streptococcus agalactiae )

“…Streptococcus agalactiae bacteremia may lead to seeding of the cardiac valves and endocarditis. Vegetations in GBS endocarditis may become extremely large with a high risk of embolization (19, 20). In the 1930s and 1940s, GBS endocarditis predominantly was associated with acute disease in pregnant and post-partum women, primarily involving the mitral valve (20).…”