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.