The conductor behind the curtain-infective endocarditis due to bicuspid aortic valve

Introduction: Aortic bicuspid valve is considered one of the most frequent congenital diseases in the adult population, ranging from 0,9-1,36%, being twice more frequent in male adults. The disease progresses to aor-tic stenosis and it is diagnosed much earlier than in ge-neral population. It also has a high risk of developing infective endocarditis especially in patients, 50 or older. We present the case of a 57-year-old male patient, wi-thout any disease and medical evaluation in the past, which addresses to the emergency department due to an altered general state, vomiting, weight loss (approxi-mately 10 kilos in six months), symptoms that started two weeks before. A multidisciplinary team evaluated the patient and decided to send him to a nephrology clinic considering the affected renal function. The blood tests were indicative of general infection and a urinary tract infection.

Methods: He presented with an altered general state, purpura disseminated on lower limbs. Oliguria was present. Considering the altered renal function rapidly progressing glomerulonephritis was considered, in the presence of oliguria, petechia, digestive symptoms and rapidly installing nitrogen retention. Due to the persis-tence of oliguria, a central venous catheter in the left subclavian was inserted, and two sessions of hemodi-alysis were performed. Renal puncture biopsy confir-med mesangial nephropathy with Ig A (Ig A-1700 mg/ dl) (Berger disease/ Henoch Shonlein purpura). In the 23rd day of hospitalization, during the night, the pati-ent suffered sudden-onset dyspnea. On the ECG there was de novo ST horizontal segment depression of 1-1,5 in V5 and V6 and echocardiography revealed se-vere hypokinesis of the apical half of the interventricu-lar septum and anterior wall of the left ventricle with moderate left ventricular systolic dysfunction (ejection fraction 30-35%). On the free leaflet margin of the mi-tral valve, there is attached an echogenic mass of 10×5 mm size with disorderly movement.

Results: Echocardiography reevaluation after 12 ho-urs showed aortic bicuspid with oblique-horizontal slit opening, thickened, tough cusps, with coaptation defi-ciency and moderate regurgitation that caused mitral valve jet lesion and aortic valve and anterior mitral val-ve chordae tendinae vegetations. After two failed tran-sesophageal echocardiographies, and hemocultures were obtained, antibiotics were initiated. The outcome was unfavourable due to cardiac dysfunction secon-dary to the severe aortic disease followed by death.

Conclusions: Patient without medical examinations, with poor nutritional status, is hospitalized at the ne-phrology clinic due to severe renal damage, initially considered a IgA nephropathy. Later examinations re-veal aortic bicuspid valve with infective endocarditis, negative hemocultures (possibly secondary to antibio-tics initially given for urinary tract infection) and se-condary renal dysfunction due to immune complexes. Although surgery was the main treatment according to guidelines, for this patient, multiple factors contributed making the procedure unavailable.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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