WHEN CLINICAL FINDINGS TAKE YOU DOWN THE WRONG PATH: PERSISTENT FEVER IN A PATIENT WITH PREVIOUS CARDIAC SURGERY

Abstract

Abstract Introduction In a patient who underwent previous cardiac surgery, persistent fever may be related to endocarditis. Symptoms and cardiovascular imaging, such as echocardiogram and PET/CT, may guide clinicians and surgeons to the correct diagnosis. Discussion A 43–years–old man came to our attention because of persistent fever (lasting several months) associated with cough and asthenia. When he was 5 years old, he underwent cardiac surgery for partial atrioventricular canal defect (atrial septal defect was about 4 cm) and mitral valve cleft. 14 years ago he undertook chemotherapy due to Hodgkin‘s lymphoma. Recently a cerebral artery aneurysm, radiologically defined as mycotic but proved to be fusiform, was diagnosed and treated with neurosurgery. During a recent hospitalization, blood culture positive for Streptococcus Mitis and brachial rash were reported and antibiotic therapy was started. Suspecting endocarditis, he was referred to our department. Echocardiogram revealed anterior mitral leaflet fissure, resulting in severe mitral regurgitation. Moreover a periannular cavity of doubtful interpretation (seemingly an abscess) was described. Subsequent 18FDG–PET/CT did not detect any abnormal cardiac metabolic activity. Due to severe valve regurgitation, cardiac surgery was performed: myxomatous degenerative mitral valve leaflets, failure of mitral valve cleft closure and anomalous coronary sinus communication to the left atrium (mimicking echocardiogram findings of suspected empty abscess cavity) were observed. Thus mitral valve replacement using a biological valve prosthesis was performed. Macroscopically there was no evidence of endocarditis, confirming PET/CT scan results. During the post–surgery period, third–degree atrioventricular block episodes were noted. Therefore a bicameral pacemaker was implanted. Conclusions This case report demonstrates the importance of not stopping at the first impression, as failure of previous mitral valve repair in a patient presented with persistent fever can mimic endocarditis. Therefore, the results of diagnostic tests should be compared to patients’ medical history and their clinical presentation.