A 54-year-old man presented with generalized weakness for a week. His blood pressure was 162/62 mmHg, heart rate 100 beats/min, and body temperature 37.2°C. One month ago, he started hemodialysis using a permanent catheter at another hospital but was lost to follow-up after discharge. Three weeks later, he visited our hospital without the catheter and described that it was removed by itself. After resumption of hemodialysis, fever up to 38.3°C developed. Serial blood cultures sampled from peripheral veins isolated Corynebacterium striatum.
Transesophageal echocardiography (TEE) was performed because transthoracic study demonstrated vegetations on the mitral valve (MV), aortic valve (AV), and tricuspid valve (TV) with severe aortic and moderate tricuspid regurgitations. Three-dimensional (3D) TEE showed multiple vegetations on the anterior and posterior MV leaflets, on the left, right, and non-coronary AV cusps, and on the 3 TV leaflets (Figure 1A, Supplementary Video 1). Large vegetations with severely destructed leaflets of the three valves were found in the operative field (Figure 1B). The valves were replaced with mechanical prostheses. Symptomatic sick sinus syndrome developed after surgery and permanent pacemaker was implanted.
Figure 1. (A) The 10×8 mm-sized and 15×7 mm-sized vegetations (arrows) on AMVL and PMVL, respectively. A 13×9 mm-sized, a 21×8 mm-sized, and a 14×11 mm-sized vegetations on the LCC, RCC, and NCC of the AV, and 10 to 22 mm-sized multiple vegetations in diameter were also found on the 3 leaflets of the TV. (B) Surgically resected AV, MV, and TV showing severe destruction with multiple vegetations.
A = anterior leaflet; AMVL = anterior mitral valve leaflet; AV = aortic valve; LCC = left coronary cusp; MV = mitral valve; NCC = non-coronary cusp; P = posterior leaflet; PMVL = posterior mitral valve leaflet; RCC = right coronary cusp; S = septal leaflet; TV = tricuspid valve.
C. striatum is an aerobic, Gram-positive bacillus that has been emerging as a nosocomial opportunistic pathogen1),2) and can rarely be associated with native valve endocarditis.3) In this case with poor medical compliance, a dialysis catheter was thought to result in C. striatum endocarditis with severe, disastrous destruction of the three cardiac valves requiring valvular replacement. 3D TEE can be helpful for meticulous evaluation of valvular morphology and function in patients with C. striatum endocarditis.
Footnotes
Conflicts of Interests: The authors have no financial conflicts of interest.
- Conceptualization: Lee SH, Kim WH.
- Data curation: Lee JY, Lee SH.
- Formal analysis: Lee SH.
- Investigation: Lee JY, Lee SH.
- Methodology: Lee SH, Kim WH.
- Project administration: Lee JY, Lee SH.
- Resources: Lee JY, Lee SH.
- Software: Lee SH.
- Supervision: Kim WH.
- Validation: Lee SH, Kim WH.
- Visualization: Lee JY, Lee SH.
- Writing - original draft: Kim JY.
- Writing - review & editing: Lee JY, Lee SH, Kim WH.
SUPPLEMENTARY MATERIAL
Three-dimensional transesophageal echocardiography showing multiple vegetations on the all cusps of the AV, MV, and TV.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Three-dimensional transesophageal echocardiography showing multiple vegetations on the all cusps of the AV, MV, and TV.