The right diagnostic track

The “path of diagnosis” often depends on the medical specialty a patient is first confronted with. If you have fever and you land on urology you end up with a complete work up for urinary tract infection, on cardiology you might get a TEE to look for endocarditis and if you are brought to rheumatology you will get an extensive lab evaluation to search for autoimmune disease.

Autoimmune disease?

This is what happened to a 42 y/o female after an 8-week history of fatigue, generalized exanthema, and fever admitted to rheumatology of a community hospital.

Indeed cANCA was positive, there were bilateral pulmonary consolidations on chest CT scan. CRP was high and the patient had leucocytosis. All of these findings led to clinical suspicion for autoimmune disease. But was this really the correct diagnosis?

The hero with the stethoscope

A young resident gave the diagnostic workup a different twist. He heard a systolic murmur. Four positive blood cultures for anaerococcus prevotii later and she was brought to our department for further evaluation.

And here is the transthoracic echo:
Parasternal long axis view demonstrating vegetations on the aortic and mitral valve

I guess you will all agree that our patient has endocardits not only on one but on both left sided valves. Since there was practically no aortic regurgitation infection must have spread from the mitral to the aortic valve (and not vice versa).

Here is the vegetation as it is seen in the 5-chamber view
Five chamber view: small mobile mass on the aortic valve

Anaerococcus prevotii is not a common pathogen for endocarditis. This gram positive pathogen can be found in and on the human body as part of the normal human microbiota on the flora of skin, vagina, nasal cavity, and feaces.

Did we miss something?

The echo findings together with the infection and positive blood cultures fulfill all criteria for an endocarditis. While the infection did not yet cause relevant mitral or aortic regurgitation we do already see some degree of mitral valve destruction.
Apical long axis view: Vegetations on the mitral- and aortic valve. The tips of the mitral valve leaflets appear thickened and destructed.
TEE study: Mild prolapse and bi valvular endocarditis. But is the more to see?
3D reconstruction of the mitral valve. The vegetation is located on the P2 and A2.

All clear so far? Not really! Why does the patient have bilateral pulmonary consolidations? And where is the explanation for the systolic murmur in this patient? Remember the patient does not have a stenotic lesion and hardly any regurgitation.

Did you catch an additional finding in the images we showed you? Do you have the power to solve this case and help the patient?

Matthias Schneider, Thomas Binder and the 123sonography team

PS: Stay tuned for the explanation in part 2

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