Subaortic aneurysm caused by Paecilomyces lilacinus endocarditis

Abstract

MOTS CLES Anevrisme sous-aortique ; Endocardites ; Echocardiographie A 41-year-old male white patient with a history of intravenous drug abuse and hepatitis C presented with bilateral peripheral thromboembolism resulting in acute occlusion of the left popliteal and the right common iliac arteries and requiring emergency surgical embolectomie. History taking and clinical examination revealed weight loss of 20 kg over 18months, asthenia and a diastolic murmur suspicious of aortic regurgitation. The patient was afebrile and CRP was only slightly elevated (18mg/l). Blood cultures and examination of the thrombi revealed fungi identified as Paecilomyces lilacinus. Transesophageal echocardiography (TEE) showed a moderately severe aortic regurgitation, a bicuspid valve with vegetations, a pseudo aneurysm of one leaflet (Fig. 1, arrow in panel A) and a subannular aneurysm communicating with the left ventricular outflow tract (Fig. 1, arrow in panel B) (see movies 1 and 2). Imaging with the real-time transesophageal three-dimensional echocardiography (3DE) yielded additional information to the 2D images and showed more clearly the bicuspid aortic valve with two equally sized leaflets and its relationship to the subannular aneurysm (Fig. 1, arrow in panel C and 3DTEE movies 3 and 4). The patient received antifungal treatment with amphotericin B and voriconazole replaced by posaconazole alone after a few days. The patient underwent uneventful surgery on the fifth day of treatment with replacement of the aortic valve and the ascending aorta by a homograft.