Infective endocarditis due to Granulicatella elegans presenting with musculoskeletal symptoms

Abstract

A 62-year-old man with essential hypertension and right L4-L5 hemilaminectomy was referred to rheumatology for evaluation of severe arthralgia and myalgia for 12 months. Review of symptoms was significant for night sweats and 20 pounds unintentional weight loss. Physical examination was significant for holosystolic murmur best heard at the cardiac apex of unclear chronicity. Laboratory investigations revealed elevated inflammatory markers, white blood cell count and B-type natriuretic peptide. Transoesophageal echocardiogram showed flail posterior mitral leaflet with severe mitral regurgitation and two vegetations (2.5×1 cm and 1.6×0.3 cm). Abdominal CT showed new focal splenic infarcts, and a brain MRI revealed subacute infarcts, consistent with the embolic phenomenon. Blood cultures grew Granulicatella elegans The patient underwent mitral valve replacement surgery followed by 6 weeks of parenteral therapy with vancomycin and gentamicin, with full recovery at a 3-month follow-up.

Keywords: infections; infectious diseases; valvar diseases.

Figure 1

Transoesophageal echocardiogram (Panel A). Long-axis midoesophageal systolic still-frame showing a flail posterior leaflet (left arrow) and large, bulky echodensity measuring 2.5×1 cm on the posterior leaflet (left arrow), which likely represent leaflet tissue and vegetation. There is a linear, highly mobile echodensity 1.6×0.3 cm on the anterior leaflet (right arrow) also consistent with vegetation. (Panel B) Same view as panel A with colour Doppler showing torrential mitral regurgitation with anteriorly directed regurgitant jet that occupies most of the left atrium. (Panel C) 3D ‘surgeon’s view’ systolic still-frame of the mitral valve from the left atrial side showing a very large prolapsing mass (arrows) associated with the posterior leaflet (P). Ao, aorta, AV, aortic valve; LA, left atrium; LV, left  ventricle.

Figure 2

CT of the abdomen and pelvis. A new focal peripheral wedge-shaped area of hypoattenuation involving the spleen likely represents sequelae of an embolic infarct.

Figure 3

MR of the brain. Several linear enhancing T2/fluid-attenuated inversion recovery (FLAIR) hyperintense lesions involving the right posterior parietal and occipital cortex and the right cerebellum consistent with the embolic phenomenon.