Case Report
We describe the case of a 59 year old female with a history of insulin
dependent type 2 diabetes and obesity, admitted to our hospital with
severe metabolic acidosis. She appeared neurologically oriented, pyretic
(38°C), with very low diastolic blood pressure values and significant
contraction of diuresis.
Electrocardiogram showed sinus tachycardia. Lab-work revealed nothing
but leukocytosis with white blood cell count of 16,000/mm3. No other
meaningful data was noted .
Trans-thoracic echocardiogram (TTE) revealed normal left ventricular
dimension and function, with ejection fraction (EF) of 65% and no
regional wall motion abnormalities. However, very large and mobile
vegetation was seen attached to the atrial side of the septal
tricuspidal leaflet, causing moderate tricuspid valve regurgitation. A
huge aortic vegetation and periannular abscess causing severe aortic
valve regurgitation was also noticed.
Trans-Esophageal Echocardiogram (TEE) revealed a tunnel among the aortic
valve, right atrium, and right ventricle, with left to right shunt, and
also confirmed the presence of voluminous masses attached to the
tricuspid and aortic valves (Fig I A).
During the following two days, despite antibiotic coverage with
intra-venous ampicillin, cefazolin and gentamicin since admission, the
patient rapidly worsened, requiring support of high doses of inotropes
and intubation. Moreover, she developed acute kidney injury and
worsening anemia.
A total body CT scan was performed to exclude possible peripheral
embolization and identify possible sites of infection. The test gave
negative results.
Thus, we decided to perform urgent surgery.