Case Report
Written informed consent was obtained from the patient for the
publication of this case report. At our medical center,
institutional review board
approval is not required for the publication of case reports.
An 18-year-old man presented to his local doctor with a 5-day fever and
transient loss of consciousness. The loss of consciousness was not
preceded by any signs, and no seizure activity was observed before or
after the event. Thoracoabdominal computed tomography (CT) and head CT
did not indicate any source of fever or cause of loss of consciousness;
however, echocardiography showed a suspected verruca at the posterior
mitral valve leaflet, prompting referral to our hospital with a
diagnosis of infective endocarditis.
The patient had no history of cardiac disease, areas in the oral cavity
requiring treatment, or history of drug use that may have contributed to
the development of infective endocarditis. However, he had atopic
dermatitis since childhood and had an exacerbation of facial erythema 4
months earlier, which subsequently improved 1 month prior.
Upon arrival at our hospital, he was alert but had a temperature of
38.7°C. No paralysis or other neurological abnormalities were noted. His
skin condition was not poor and his abrasions were mild. Osler’s nodes
were observed in both hands, and the right shoulder was tender,
prompting suspicion of a septic shoulder.
The blood tests showed a white-blood cell count (WBC) of 14700 IU/dL,
with neutrophilia but no leftward shift; C-reactive protein (CRP) level
of 14.20 mg/dL; and procalcitonin level of 1.00 ng/mL. There was no
anemia, and the liver and renal functions were normal. Blood culture
showed methicillin-sensitive Staphylococcus aureus (MSSA). No
other bacteria were detected. Echocardiography showed a verruca on the
posterior mitral valve leaflet, which was mobile and about 10 mm in size
(Fig. 1); mitral regurgitation was mild. Head magnetic resonance imaging
(MRI) showed multiple acute cerebral infarctions in the left frontal
deep white matter, bilateral occipital lobes, and corpus callosum
ampulla (Fig. 2). Enhanced CT showed renal infarction and splenomegaly
(Fig. 2). Spinal MRI showed no evidence of pyogenic spondylitis.
Antibiotic therapy was started and the patient was referred to our
cardiovascular surgery department. Since systemic embolism was observed,
we considered further embolism as highly likely and decided on urgent
surgery.
MICS was performed through a small right thoracotomy. A verruca was
found on the left atrial wall near the posterior mitral valve annulus. A
small verruca was also seen on the anterior mitral valve leaflet (Fig.
3). Since there was no destruction of the mitral annulus and leaflet,
verrucous excision was performed. Culture of the excised verruca also
showed MSSA.
Postoperatively, vancomycin and ceftriaxone were continued for 2 weeks
and 6 weeks, respectively. There were no neurological complications and
his general condition improved. His right shoulder pain was relieved,
allowing him to elevate his right shoulder. Postoperative head MRI
showed no new cerebral infarcts and the abnormal signals disappeared.
Further, there was no evidence of abscess formation or hemorrhage.
Enhanced CT of the abdomen showed no significant evidence of renal
infarction, and no exacerbation. There was no renal dysfunction.
Echocardiography also showed no recurrence of verrucae.
The patient was discharged from the hospital after his fever abated.
Blood tests showed a WBC count of 7800 IU/dL and a CRP level of 0.05
mg/dL. One year postoperatively, the patient had no recurrence of
infection and no complications.