Case Presentation: A 29-year-old female with a PMH of uncontrolled type I DM complicated by gastroparesis and neuropathy, gastritis, chronic hep C, polysubstance abuse, chronic narcotic dependence on subutex, and DVT presented with SOB, abdominal pain, and LE edema. She recently returned from a cruise in the Bahamas where the symptoms began one week prior. At that time, she was evaluated by the ship physician who was concerned she may have pulmonary edema, instructing her to present to the ED upon return. She additionally endorsed fevers, chills, cough, congestion, malaise, and nausea vomiting. History of abdominal pain following established at Chapel Hill with planned outpatient MRCP for biliary sludge.  

 

On presentation, she was ill appearing, lethargic, and in resp distress. Tachycardic to 126 with She was afebrile but with an elevated temperature of Temp 100.1 F. Respiratory rated was increased with hypoxia to SpO2 85-90%. Resolved after 2-3L NC Audible upper airway congestion and coarse bilateral lung sounds were present on exam. WBC 10.9 with lactic of 4.4. CXR was unremarkable with CT PE negative but noted multiple scattered pulmonary nodules concerning septic pulmonary emboli. RUQ US negative for cholelithiasis or cholecystitis in the setting of abdominal pain. 

 

BC positive for Streptococcus mitis and she was initiated on cefazolin with ID consulted for long term antibiotics. TTE noted structurally normal mitral valve with mild regurgitation. Leaflets appeared mildly thickened. There is systolic anterior motion of the chordae tendonae. Cardiology was thus consulted and preformed TEE notable for a mobile echodensity attached to the chordal apparatus of the mitral valve. Though a very unlikely location for vegetation formation, it could not be ruled out. Unusual place for vegetation but unable to exclude.  There was additionally noted mobile echodensity attached to the catheter of SVC suspicious for vegetation as well. It was subsequently removed. Repeat echo one week later noted new vegetation on anterior leaflet of the mitral valve. 

 

Final/Working Diagnosis: Vegetation of the Mitral valve Chordae Tendonae

 

Management/ Outcome/and or Follow-up: Completed full course of antibiotics for Strep bacteremia and vegetation with cleared blood cultures. Course further complicated by CLABSI from PICC due to Acinetobacter and Candida. PICC removed and completed course of Unasyn and Micafungin.

 

References:

1. “Infective Endocarditis.” NORD (National Organization for Rare Disorders), 20 July 2020, https://rarediseases.org/rare-diseases/endocarditis-infective/. 
2. Infectious Endocarditis – StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK557641/. 
3. Chamat-Hedemand, Sandra, et al. “Prevalence of Infective Endocarditis in Streptococcal Bloodstream Infections Is Dependent on Streptococcal Species.” Circulation, 25 June 2020, https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.046723. 
4. Ashley EA, Niebauer J. Cardiology Explained. London: Remedica; 2004. Chapter 10, Infective endocarditis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2208/
5. “Medical Knowledge Self-Assessment Program.” ACP, https://mksap18.acponline.org/app/topics/cv/mk18_a_cv_s6/mk18_a_cv_s6_9_1.