Case Report
A 52-year-old female patient was referred to our university medical center with suspected acute infectious endocarditis (IE). Nine days before, an ischemic stroke of the left middle cerebral artery had been diagnosed at the referring hospital. ECG showed no evidence of atrial fibrillation supporting cardioembolic events. A transesophageal echocardiography was performed and vegetations adherent to the in-situ port catheter and the aortic valve were found. An acute infective endocarditis was suspected and calculated antibacterial treatment with ampicillin and gentamicin was initiated. Because of respiratory distress a computed tomography of the pulmonary arteries was performed, which revealed bilateral pulmonary embolism. Thereupon, the patient was referred to our tertiary care hospital for further therapy.
Medical history revealed that the patient had clear cell carcinoma of the cervix at an advanced stage (FIGO IV4A). The carcinoma had been diagnosed one year ahead of the current admission and initially treated with lymphadenectomy, and concurrent platinum-containing radiochemotherapy. With recently identified lymphogenic progression, therapy with Navelbine had been initiated. In addition, the patient had a history of pulmonary embolism in November 2020 since then followed by oral treatment with the direct factor Xa inhibitor Edoxaban for therapeutic anticoagulation.
On admission to our unit, the patient presented with severe hemodynamic instability reflected by tachycardia and hypotension. Respiratory distress required a high flow oxygen support (10 l/min) via facial mask. The patient had no fever. Laboratory findings showed moderately elevated c-reactive protein (137mg/l), normal procalcitonin (0.5 ng/ml) an normal leukocyte counts (9.43/nl). Moreover, we detected mild thrombocytopenia (115/nl), anemia (serum hemoglobin 7,3g/dl) and highly elevated d-dimers (15 mg/l). Notably, Troponin I (11462 pg/ml) and BNP (2624 pg/ml) were as well elevated (Tab. 1 for relevant laboratory findings on admission).
Bedside transthoracic echocardiography on admission suggested large vegetations affecting the aortic valve, so we performed an urgent transesophageal echocardiography. Consistent with the earlier examination, we found large vegetations, but not only on the aortic valve (Fig. 1 ) also affecting the mitral (Fig. 2 A/B ) and the tricuspid valve (Fig. 2C ) with large floating masses within the right ventricle extending over the pulmonary valve into the pulmonary artery (Fig. 2D ). Notably, although the vegetations were very pronounced, there was no destruction of the valves and only moderate insufficiencies could be visualized (Fig. 1B/2B/2C ). We also detected vegetations adherent to the right side of the atrial septum (Fig. 3 ) and impaired systolic function of the left ventricle.
We initiated microbiological diagnostics by taking three pairs of blood cultures as well as next generation sequencing (NGS)-based diagnostics for pathogen identification and extended the antibiotic therapy by Flucloxacillin according to guidelines for IE. Given the malignant underlying disease and the low values of PCT, we additionally started therapeutic anticoagulation with unfractionated heparin and performed extended thrombophilia and coagulation diagnostics (Tab. 2 ).
After multidisciplinary discussion of the case, a joint decision did not see surgical therapy as a favorable option. Following circulatory deterioration the patient died on our ICU due to shock-associated multiple organ failure only two days later.