Radiology Teaching Files > Case 18399413

Contributed by: Jennifer Sloan, Mountain State University, West Virginia, USA.
Patient: 44 year old female
History: A 44 year-old female came in with a fever of unknown origin.  She was also an IV drug abuser.  She was 165cm tall and weighed approximately 47.20 kg making her BSA 1.5 m squared.  Her BP was 119/69 mmHg.  
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Findings: A 2D Echo  and M- Mode Doppler was performed showing the following:
     RV in Diastole: 2.4  cm 
     IVS in diastole : 1.3cm
     LV in Diastole:  5.3 cm 
     LVPW in Diastole:  1.2 cm 
     AOR in Diastole:  3.6 cm 
     LV in Systole:  3.5 cm
     LA in Systole:  3.78 cm 
     LV EF: 62.0%

Mitral Valve
     E Vmax:  1.25 m/s
     A Vmax:  0.66 m/s
     E/A:  1.88

Tricuspid Valve
     TR Vmax:  2.72 m/s
     TR Pk Grad:  29.6 mmHg
     RA Pressure:  10 mmHg
     RVSP: 39.6 mmHg

Left Ventricle:  Has an estimated EF of 50-55%
Right Ventricle:  Is normal.
Left Atrium:  Is considered to be mildly dilated.
Right Atrium:  Is mildly dilated.
Aortic Valve:  Is trileaflet and normal.
Mitral Valve:  Moderate mitral annular calcification.  Mild mitral valve regurgitation.
Tricuspid Valve:  Is normal in structure.  Mild tricuspid regurgitation.  The estimated right ventricular systolic pressure is borderline elevated. 
     1. The left ventricle has an estimated EF of 50-55%
     2. Moderate concentric left ventricular hypertrophy.
     3. Right atrium is mildly dialted.
     4. Borderline elevated PA systolic pressure.
     5. Mild tricuspid regurgitation.
     6. The aortic valve is trileaflet and normal.
     7. The left atrium is mildly dialted.
     8. Mild mitral valve regurgitation.
     9. Mobile vegetation on the mitral valve.
     10. Moderate mitral annular calcification.
     11. No pericardial effusion.

Diagnosis: The diagnosis was a vegetation on the mitral valve leaflet from endocarditis.
Discussion:      Endocarditis is a cause of vegetations on the heart valves.  Endocarditis is exudative and proliferative inflammatory alterations of the endocardium characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but also affecting the inner lining of the cardiac chambers or the endocardium elsewhere.  Lesions on the valves may interfere with the ejection of blood from the heart by causing insufficiency or stenosis of the valves.  Murmurs associated with heart sounds are the major manifestations and of interference with blood flow is sufficiently severe congestive heart failure develops.  The further hazard with endocarditis, especially if it is bacterial in origin, is that of septic emboli in the lungs or in the other organs.

     In a healthy individual, a bacteriemia would normally be cleared quickly with no adverse consequences.  If a heart valve is damaged and covered with a piece of a blood clot, the valve provides a place for the bacteria to attach themselves and an infection to establish.  Another group of causes result from a high number of bacteria getting into the bloodstream.  Colorectal cancer, serious UTI and IV drug use can all introduce large numbers of of bacteria.

     Clinical and pathological features include:
          Continuous presence of micro-organisms in the bloodstream determined by serial 
          collection of blood cultures
          Vegetations on the valves 
          Vascular phenomena: Septic emboli, Janeway lesions, intracranial hemorrhage, 
          conjunctival hemorrhage, and splinter hemorrhages
          Immunologic phenomena:  Glomerulonephritis, Osler's nodes, Roth's spots on the 
          retina, positive serum rheumatoid factor

     Treatment includes high dose antibiotics are administered intravenous route to maximize diffusion of antibiotic molecules into vegetations from the blood filling the chambers of the heart.  Antibiotics are continued for about 2-6 weeks.  Surgical removal of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection.
References: Gay, C., & Studdert, V.  (2007).  Veterinary Dictionary.  Saudes Comprehensive 
     Veterinary Dictionary 3rd ed., p. 1-5., Retrieved August 7, 2008., Retrieved August 7, 2008. 
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Additional Details:

Case Number: 18399413Last Updated: 08-15-2008
Anatomy: Heart   Pathology: Infection
Modality: USAccess Level: Readable by all users

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