A rare case of anaerobic streptococci endocarditis in a young female with bicuspid aortic valve: case report

Abstract

Background: Bicuspid aortic valve is the most common congenital cardiovascular malformation and occurs in 1-2% of the population. The haemodynamic changes appear early, leading to tissue damage and predisposing to germs attachment. The development of perivalvular extension is a constant in bicuspid aortic valve endocarditis. Infective endocarditis with anaerobic bacteria is a rare condition with a high rate of mortality.

Case summary: We report a case of a young female with bicuspid aortic valve infective endocarditis. Involved bacteria were anaerobic streptococci, and the clinical course of the diseases was very aggressive. The echocardiographic evaluation revealed aortic and mitral regurgitation, perivalvular abscess, ventricular septum defect, and pericardial effusion. The surgery approach consisted of the aortic valve replacement with a mechanical prosthesis after radical resection of aortic root abscess and reconstruction of the annulus. The ventricular septum defect was also closed with a pericardial patch. Anticoagulation started the first day after surgery. The patient was received antibiotic therapy for 10 days before and 4 weeks after surgical intervention. Evolution was very good at 1 and 6 months follow-up.

Discussion: This is a severe case of endocarditis, complicated with extensive valvular destruction, aortic root abscess, and fistula. Perivalvular complications are frequent in patients with bicuspid aortic valve endocarditis. The 'take away' message is that echocardiography is an essential tool for diagnosis, management, and follow-up of patients with infective endocarditis.

Keywords: Bicuspid aortic valve; Case report; Echocardiography; Infective endocarditis.

Figure 1

(A) Chest radiographs—cardiomegaly and diffuse interstitial prominence. (B) Transthoracic echocardiography—parasternal short-axis view at the level of great arteries with zoom—bicuspid aortic valve with two thick aortic leaflets and dome opening. (C) Transthoracic echocardiography—parasternal long-axis view—vegetation at the level of aortic valve, pericardial effusion. (D) Transthoracic echocardiography—parasternal long-axis view—aortic regurgitation, pericardial effusion. (E) Transthoracic echocardiography—parasternal long-axis view—mitral regurgitation, pericardial effusion. (F) Transthoracic echocardiography—modified parasternal short-axis view at the level of papillary muscles: ventricular septum defect, pericardial effusion, pleural effusion.

Figure 2

(A) Transoesophageal echocardiogram—short-axis view at the level of aortic valve: bicuspid aortic valve with vegetations, aborted abscess at the level of mitral-aortic intervalvular fibrosa area. (B) Transoesophageal echocardiogram—long axis at the level of aortic valve: vegetations at the level of aortic valve, aborted abscess at the level of mitral-aortic intervalvular fibrosa area. (C) Transoesophageal echocardiogram—long-axis view at the level of aortic valve: aortic regurgitation, vegetations at the level of aortic valve, aborted abscess at the level of mitral-aortic intervalvular fibrosa area. (D) Transoesophageal echocardiogram—long-axis view at the level of aortic valve: mitral regurgitation, vegetations at the level of aortic valve. (E) Transoesophageal echocardiogram—long-axis view: ventricular septum defect. (F) Transoesophageal echocardiogram—CW Doppler: restrictive ventricular septum defect with left to right flow, pressure gradient 112 mmHg.

Figure 3

(A) Transthoracic echocardiography—parasternal long-axis view: mechanical prosthesis in aortic position—at 1-month follow-up visit. (B) Transthoracic echocardiography—parasternal long-axis view: mechanical prosthesis in aortic position with colour Doppler showing normal flow—at 1-month follow-up visit. (C) Transthoracic echocardiography—CW Doppler at the level of mechanical prosthesis in aortic position- maximal pressure gradient 38.24 mmHg—at 1-month follow-up visit. (D) Transthoracic echocardiography—parasternal long-axis view: mild mitral regurgitation—at 1-month follow-up. (E) Transthoracic echocardiography—CW Doppler at the level of mechanical prosthesis in aortic position-maximal pressure gradient 37.47 mmHg—at 6-month follow-up visit.