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.