A new entity in an immunosuppressive patient: Giant reverse kissing vegetation

Abstract

Article history: Received 4 August 2015 Accepted 6 August 2015 Available online 13 August 2015 and Video 1). Empiric triple antibiotic therapy was started immediately after taking three bottles of blood culture. Two days later, his control TTE showed the same aortic vegetation and also thickening in themitral valve anterior leaflet. In addition, it was established that the thickening was clearly at the basal part of the anterior leaflet, which was close to the aortic–mitral continuity (Fig. 1C and D and Video 2). Meanwhile, a coagulase negative Staphylococcus was identified in two separate Infective endocarditis (IE) is a fatal disease which poses a large scale of presentation and warrants meticulous attention in both diagnosis and treatment [1–8]. Any of the heart valve and endocardial tissues could become involvedwith IE andmore than one structure could be infected at the same time. The infection could be transmitted inside of the heart due to the proximity of the structures. It has been recognized that IE in the aortic valve position has a high predilection for perivalvular extension of infection to involve the mitral-aortic intervalvular fibrosa (MAIF) [8]. The MAIF is the fibrous zone of continuity between the non-coronary cusp of the aortic valve and the insertion of the anterior mitral valve leaflet. As the MAIF is the least vascular structure of the heart, it ismore susceptible to infection andmycotic false aneurysm formation. Hence, the MAIF could be a way for aortic valve endocarditis to spread to themitral valve. Karalis et al. defined in their study that aortic valve endocarditis could cause MAIF abscess, MAIF perforation in the left atrium, anterior mitral leaflet (AML) aneurism and AML perforation [9]. Hence, they pointed out that sub aortic structures, aortic root and AML should be meticulously sought for early detection of the mitral valve invasion in cases of aortic valve IE. In this particular case, we demonstrate rapid progression of IE that wrapped both the aortic andmitral valves in an immunosuppressive patient and also discuss the mechanism of mitral valve kissing vegetation. A 69-year-old male patient was admitted to our clinic because of shortness of breath, palpitations and fever. He had been diagnosed with myelofibrosis six months previously. He had also undergone a splenectomyoperation,whichhad become complicatedwithwound infection threemonths prior to admittance. After the operation, hewas on lenalidomide therapy. In his followup, his hematologist hadmade a cardiology consultation because the patient experienced shortness of breath and palpitations. A large mobile mass considered to be a vegetation was seen on transthoracic echocardiography (TTE) (Fig. 1A and B