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Case of the week

  • Endocarditis
  • Author: Shirjel Alam

A 27 year old man presented to hospital with a high fever and history of weight loss. He was extensively investigated but examination, blood cultures, viral serology and radiological examination was negative. An echocardiogram was requested as part of a septic screen.

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Movie 1: A large vegetation is seen on the posterior leaflet of the mitral valve.

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Movie 2: The vegetation can be seen to almost prolapse through the mitral valve.
Figure 1 the vegetation measured 1.3 x 1.9 cm
Figure 1: The vegetation measured 1.3x1.9cm

The mitral regurgitant murmur was not readily audible despite the size of the vegetations. The patient suffered from embolic phenomena, and so was referred for surgery. The vegetation was removed and the mitral valve repaired. PCR analysis eventually revealed a Haemophilus species as the culprit.
Transthoracic echocardiography is 40-80% sensitive in the diagnosis of endocarditis.

Features suggesting possible endocarditis on echocardiogram
  • Regurgitant jet
  • Visualisation of vegetation
  • Flail aortic valve cusp
  • Flail mitral valve leaflet
  • Para-prosthetic leaks

    Endocarditis cannot be excluded with a negative trans-thoracic study, and so a trans-oesophageal study is often indicated.

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