Abstract
We report an unusual case of infective endocarditis (IE) in an 88-year-old woman, occurring on a prolapsing mitral valve and characterized by an atypical vegetation shape resembling a spiral-like appearance. After the patient refused surgical correction, persistent IE despite prolonged antibiotic therapy was observed, resulting in an ischemic stroke probably secondary to septic embolus. The importance of vegetation shape in the management of patients with IE was classically related to the increased risk of embolization associated with pedunculated, irregular, and multilobed masses. We hypothesize that the unusual spiral-like vegetation shape in our patient may have favored IE persistence by two mechanisms, namely, a decrease of the exposed vegetation surface with creation of an internal core where the penetration of antimicrobial agents was obstacled and the creation of blood turbulence within the vegetation preventing a prolonged contact with circulating antibiotics. These considerations suggest that vegetation shape might be considered of importance in patients with IE not only because of its classical association with embolization risk, but also because of its potential effect on the efficacy of antibiotic therapy.
Highlights
Infective endocarditis (IE) is a major cause of morbidity and mortality worldwide, and stroke secondary to septic embolus is a major and potentially life-threatening complication of left-sided infective endocarditis (IE) [1]
We report a case of persistent IE followed by ischemic stroke, where an atypical vegetation shape might have contributed to reduce the penetration of the antimicrobial agents, favouring IE persistence and septic embolization
Echocardiography plays a key role in the clinical management of patients with IE, providing valuable information for IE diagnosis, identification of complications such as heart failure or abscesses, indications to surgery, and prognostic stratification [3, 4]
Summary
Infective endocarditis (IE) is a major cause of morbidity and mortality worldwide, and stroke secondary to septic embolus is a major and potentially life-threatening complication of left-sided IE [1]. Prompt starting of adequate antibiotic therapy, and surgery when appropriate are the cornerstones of successful IE treatment, it is known that the ability of antimicrobial agents to penetrate into the vegetations is a key factor to determine the clinical outcome of IE patients [2]. We report a case of persistent IE followed by ischemic stroke, where an atypical vegetation shape might have contributed to reduce the penetration of the antimicrobial agents, favouring IE persistence and septic embolization
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