Abstract
Described herein is a 68-year-old man with end-stage renal disease on hemodialysis who was found to have methicillin-sensitive Staphylococcus aureus endocarditis with an associated ring abscess that extended into the left atrioventricular sulcus and ruptured into the pericardial space causing pericardial effusion. In contrast to the frequency of infective endocarditis involving the aortic valve, ring abscess associated with infection of the mitral valve is uncommon.
Keywords: Infective endocarditis, mitral valve, ring abscess
Infective endocarditis (IE) with ring abscess occurs mainly with infection involving the aortic valve.1,2 IE with a ring abscess isolated to the mitral valve is uncommon, but such was the case in the patient described herein.
CASE REPORT
A 68-year-old Hispanic man with end-stage renal disease presented to the emergency department with several days of altered mental status, chest pain, dizziness, nausea, and chills. A week earlier he had transitioned from a temporary catheter to an upper extremity fistula for hemodialysis. In the emergency department, he was hypotensive and in atrial fibrillation with a ventricular rate of 134 beats/min. His blood lactate was 6.7 mmol/L, troponin 6.6 ng/mL, D-dimer 14.67 mcg/mL, and C-reactive protein 21.5 mg/dL. He was given fluids, antibiotics, and heparin intravenously. Blood cultures from admission grew methicillin-sensitive Staphylococcus aureus. On the third day of hospitalization, the patient had cardiac arrest; resuscitation was successful. An echocardiogram after the cardiac arrest disclosed a pericardial effusion. A subsequent cardiac arrest was fatal. Autopsy revealed mitral valve endocarditis with a ring abscess extending into the left atrioventricular sulcus with rupture into the pericardial space producing hemorrhagic pericardial effusion (Figure 1).
Figure 1.
Heart in the patient described. (a) Exterior view showing the acute pericarditis. (b) Left parasagittal cut showing the left side of the heart. A vegetation is barely seen on the atrial aspect of the posterior mitral leaflet. As shown better in (c), the mitral vegetation has ruptured into the left atrioventricular sulcus and then out into the pericardial sac, causing a large hemopericardium. (d) Shown here is the mitral vegetation “head on.” The underlying mitral valve is anatomically normal. Only a minute calcific deposit was present in the mitral annular region.
DISCUSSION
The patient described herein required hemodialysis for end-stage renal disease, initially with a temporary catheter and recently with an arteriovenous fistula. Patients on chronic hemodialysis have a high incidence of IE. The Danish National Patient Registry reported a frequency of IE in patients undergoing hemodialysis of 1092 per 100,000 person-years.3 The risk of IE in patients with central venous catheters for hemodialysis was more than double that of those receiving hemodialysis via arteriovenous fistulas.3
IE more commonly affects a native aortic valve than a native mitral valve. Analysis of 96 necropsy patients with active left-sided IE studied by Arnett and Roberts1 disclosed isolated aortic valve involvement in 34 patients (35%), isolated mitral valve involvement in 22 patients (23%), and involvement of both valves in 18 (19%).1 Of 59 patients with IE involving the aortic valve, 24 (41%) had a ring abscess; of 36 patients with IE involving any valve other than the aortic, only 3 (6%) had a ring abscess.2 At least five patients with IE involving the mitral valve and leading to ring abscess and pericarditis have been reported previously; three had the IE superimposed on a calcified mitral annulus.3–6
Pericarditis is a relatively uncommon complication of IE. Arnett and Roberts2 found pericarditis in 18 (19%) of 95 patients with IE involving the aortic valve, 14 of whom had a ring abscess. The same authors found pericarditis in only 6 (12%) of 48 patients with IE involving the mitral valve, only one of whom had a ring abscess. What makes our patient’s pericarditis unusual is that it was in the setting of isolated mitral valve IE. Causes of pericarditis in patients with IE are summarized in Table 1.
Table 1.
Causes of pericarditis in infective endocarditis
I. Extension of inflammation from
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References
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