Case 25-1998

Abstract

A 34-year-old man was admitted to the hospital because of worsening dyspnea and increasing mitral regurgitation after replacement of the aortic valve for acute bacterial endocarditis.The patient had a history of intravenous drug abuse. Four months before admission he had been transferred to this hospital because of acute bacterial endocarditis caused by Staphylococcus aureus, with aortic regurgitation. A test for antibodies to the human immunodeficiency virus was negative. A transesophageal ultrasonographic examination of the heart (Fig. 1) revealed a large prolapsing vegetation on the right coronary cusp of the aortic valve, with severe aortic regurgitation; there was a small mobile vegetation on the septal leaflet, associated with moderate tricuspid regurgitation. Oxacillin, gentamicin, ceftriaxone, and metronidazole were administered.A computed tomographic (CT) scan of the brain showed three enhancing foci, each less than 1 cm in diameter, in the subcortical white matter, a finding consistent with septic embolism. An abdominal CT scan showed multiple splenic infarcts and probable focal infarction or necrosis of an ileal loop, with perforation. The infarcted, perforated segment of terminal ileum and the infarcted spleen were resected, and a pelvic abscess was drained. Subsequently, the aortic valve and a large vegetation were excised (Fig. 2), and a Carpentier-Edwards prosthetic pericardial valve was inserted; an adjacent abscess and a vegetation on the septum near the tricuspid valve were débrided. The patient was discharged, free of symptoms, on the 46th hospital day, after having received oxacillin intravenously for 42 days; warfarin therapy was continued.Five weeks after discharge, a low-grade fever developed, with occasional chest pain, cough, chilliness, sweats, and increasing dyspnea. Clarithromycin was ineffective in treating these symptoms, and after one week the patient returned to the hospital.Examination revealed that the temperature was 37.7°C. The jugular venous pressure was 10 cm, and crackles were heard at both lung bases. A grade 2 systolic murmur was transmitted from the apex to the axilla. The results of a urinalysis were normal. The urea nitrogen and creatinine levels were also normal. The results of other laboratory tests are shown in Tables 1 and 2.