Myocardial Abscess Research Articles

Intramyocardial abscess and endoventricular thrombosis: a complex case

Infective endocarditis (IE) is today a public health problem, as the recent ESC Guidelines have also recalled. Abscesses can be complications of IE and their presence means that the infection is not controlled. We describe the complex case of a 57-year-old patient, presented in ED for fever and oleocranical bursitis, increase of cardiac enymes at blood samples. He was admitted to our Cardiology Unit because TTE showed a floating peduncolated formation in the left ventricle. The susequent TEE documented also the presence of a myocardial abscess, confirmed at cardiac MRI. Blood cultures were positive for MSSA and the man received specific antibiotic therapy. Anticoagulation treatment was started with UFH and then switched to Warfarin, surgical approach of the lesion would have been too dangerous according to Cardiac Surgeons. Serious and sudden neurological complications then followed, leading the patient to brain death in ICU.

A Very Rare Case of Primary Mural Endocarditis of the Right Atrium due to Candida Albicans

Right-sided infective endocarditis accounts for 5-10% of all infective endocarditis cases. Fungal endocarditis represents 1-3% of all of infective endocarditis cases, with Candida spp. being the most common microbiological cause. Primary mural endocarditis is defined by the absence of valvular vegetations together with the presence of vegetations on the endocardial free wall that are not associated with myocardial abscesses, cardiac structural abnormalities, devices, prosthetic material, thrombi or tumors. It constitutes a very rare entity and only 63 cases have been published the literature. C. albicans is the microbiological cause in only nine of these cases, none of which involves the right atrium. We report the case of a frail 84-year-old female patient with a pacemaker presenting with fever. In the transthoracic and three-dimensional transesophageal echocardiograms, a mobile mass was found attached on the free wall of the right atrial base. Blood cultures were positive for C. albicans and the modified Duke criteria were fulfilled for a definite diagnosis of infective endocarditis. After evaluation from a heart team the patient was managed with transvenous lead extraction and intravenous high-dose caspofungin, according to the 2023 Guidelines of the European Society of Cardiology for the management of endocarditis. Pacemaker lead cultures were negative leading to the diagnosis of primary mural endocarditis. The patient responded well to treatment with significant clinical and laboratory improvement. Long-term oral fluconazole was initiated after hospital discharge with a close follow-up plan. To our knowledge this is the first case of primary mural endocarditis of the right atrium due to C. albicans.

Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression was useful in a patient with isolated myocardial abscess confined to the right atrial wall: a case report

BackgroundMyocardial abscess is often associated with infective endocarditis (IE), and isolated myocardial abscess without IE is rare. Echocardiography and computed tomography (CT) are often used to diagnose myocardial abscess; however, to the best of our knowledge, diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression (DWIBS) has not been used. Here, we present a case of myocardial abscess without IE that was diagnosed using DWIBS.Case presentation: A 72-year-old Japanese man with a history of hypertension, dyslipidemia, and retinitis pigmentosa presented to our hospital with malaise and a fever lasting 10 days. Blood test results showed elevated inflammatory marker levels (white blood cell count 18,700/µL and C-reactive protein level 23.0 mg/dL). Infection was suspected; however, the source of the infection could not be identified. DWIBS, which was performed on day 7 of admission to determine the source of infection, showed a high signal surrounding the right wall, suggesting inflammation. Contrast-enhanced CT performed on day 1 of hospitalization revealed a low-density area in the same region; however, the pathological implications of this finding could not be determined. Based on DWIBS findings, we concluded that the condition presented as a myocardial abscess that was confined specifically to the right atrial wall. Three sets of blood cultures revealed negative findings, and echocardiography showed no vegetation or valve regurgitation. Therefore, the patient was diagnosed with an isolated myocardial abscess uncomplicated with IE. An electrocardiogram on admission showed no P waves, and the patient had a junctional rhythm. However, on day 20 of hospitalization, he developed a complete atrioventricular block. After complete myocardial abscess healing following antibiotic treatment was confirmed, the patient underwent pacemaker implantation. Ten months after surgery, the patient had no signs of infection recurrence.ConclusionsBased on history and physical examination alone, diagnosis of an isolated myocardial abscess can be challenging. In addition to CT and echocardiography, DWIBS might be helpful for the diagnosis of myocardial abscesses.

Coronary Stent Infection Complicated by Persistent Methicillin-Sensitive Staphylococcus aureus Bacteremia Myocardial Abscess and Pericardial Effusion

A 52-year-old man presented with coronary stent infection complicated by persistent methicillin-sensitive Staphylococcus aureus bacteremia, myocardial abscess, and pericardial effusion treated successfully with medical management. We presented an updated literature review of diagnosis, treatment, and outcomes of coronary stent infections. We recommend that providers have a high index of suspicion in patients with fevers, leukocytosis, bacteremia, and/or new acute coronary syndrome within 30 days of coronary stent placement. Multimethod imaging, including echocardiography, computed tomography, magnetic resonance imaging, and cardiac positron emission tomography, can assist in diagnosis. Although early-onset infection may be effectively treated with medical therapy alone, late-onset infections appear to benefit from antimicrobials and surgical intervention.

Septal myocardial abscess in a Thoroughbred mare

SummaryAn 11‐year‐old multiparous Thoroughbred mare with a history of colic was referred for further evaluation. Clinical findings at the time of initial examination included arrhythmia, tachycardia, tachypnoea and hypothermia without marked signs of abdominal pain. Electrocardiography revealed ventricular tachycardia at a rate of 211 beats/min. Lidocaine was administered as a constant rate infusion to treat the arrhythmia, and the heart rate and rhythm were normalised. There were no abnormal findings on ultrasonography of the abdomen and thorax. An echocardiographic examination revealed a hypoechoic spherical area within the muscular part of the intraventricular septum. Unfortunately, the mare died suddenly 3 days after treatment. Post‐mortem examination confirmed the presence of an encapsulated abscess in the intraventricular septum. Staphylococcus aureus and Staphylococcus chromogenes were isolated from the lesion. It was thought to be responsible for the arrhythmia seen in this case. This is the first case of a septal myocardial abscess in a horse.

Infective endocarditis with systemic bacterial embolism caused by Staphylococcus aureus in a free-ranging Amami rabbit (Pentalagus furnessi)

The Amami rabbit (Pentalagus furnessi) is found only on the two islands of Amami-Ōshima and Tokunoshima in southwest Japan. It has a primitive appearance and ecology, is an evolutionarily valuable animal and has been assigned to the International Union for Conservation of Nature Red List of Threatened Species. We describe a case with mild purulent wounds on the distal digital skin of both forelimbs and multiple nodular lesions in various organs, including the heart and kidney. Microscopically, the heart lesions were characterized by disruption of the mitral valve and multifocal myocardial necrosis and abscesses due to infection with gram-positive cocci. Similar bacterial infarctions were also found in other organs, including the kidneys. The bacteria were identified as Staphylococcus aureus by immunohistochemical and molecular biological examinations. This first report of infective endocarditis and systemic infarctions caused by S.aureus in an Amami rabbit indicates the importance of monitoring purulent injuries, even if mild, to prevent secondary infections in this species.

809 A CASE OF CASEOUS MITRAL ANNULUS CALCIFICATION

Abstract Caseous mitral annular calcification (CMAC) is a rare variant of degenerative mitral annular calcification (MAC) with an echocardiographic prevalence of 0.6% of all MACs and an overall prevalence of up to 0.07% in the general population. It primarily affects older patients with hypertension and chronic kidney disease. Due to the general benign prognosis, conservative management of this lesion is recommended in most cases. Herein we describe the case of a 78-year-old female patient admitted for sustained ventricular tachycardia treated with Amiodaron infusion followed by electrical cardioversion for hemodynamically instability. Her past medical history was remarkable for hypertension, HFpEF and chronic kidney disease. Trans-thoracic echocardiogram showed the presence of an echo-dense mass with central echo-lucency surrounded by calcifications at the posterior peri-annular and leaflet region of the mitral valve, not associated with valvular disfunction. To define the etiology of the arrythmia, a coronary angiography was performed and excluded significant coronary artery disease. Nevertheless, a round-shape hyperdense mass was observed in the left atrium near the atrio-ventricular groove (figure 1): during injection through coronary vessels the contrast was not visible in the lesion. In order to better define the nature of the mass, a Trans-esophageal Echocardiogram was performed and showed a “toothpaste-like” echo-dense mass with central echo-lucency surrounded by a calcified envelope at the posterior peri-annular region of the mitral valve suggestive for CMAC (figure 2); 3D zoom imaging clarified its relationship with P2 scallop of posterior mitral valve leaflet (figure 3). For the best tissue characterization and to definitely exclude other mass-like lesions, such as myxoma, papillary fibroelastoma, myocardial abscess, vegetations, lipomatous hypertrophy, Cardiac Magnetic Resonance was performed and showed low-signal intensity in both T1- and T2-weighted sequences, reflecting its calcium content. First-pass perfusion sequence reveals no contrast enhancement, whereas late gadolinium enhancement depicts a peripheral rim of enhancement confirming our suspect. In Conclusion, CMAC is a rare disorder requiring a multimodal imaging approach to differentiate it with other intra-cardiac masses. Its course is generally benign and whether not associated with valvular or hemodynamic significance, it could be considered as a bystander. Figure 1 Figure 2 Figure 3

Myocardial Abscess After Myocarditis: Advantages of Multimodal Imaging Detecting the Rare Case of Fungal Abscess

We discuss the rare case of a myocardial abscess of the left ventricle in a 42-year-old man on immunosuppressive therapy after fulminant myocarditis. Multimodal imaging detected the myocardial abscess along with other septic emboli caused by infection with aspergillus fumigatus, which could be treated effectively with antimycotic strategies. (Level of Difficulty: Intermediate.)

Staphylococcal Myocardial Abscess Eroding the Submitral Left Ventricular Free Wall Disguising as Left Ventricular Pseudoaneurysm in a Toddler

Staphylococcal Myocardial Abscess Eroding the Submitral Left Ventricular Free Wall Disguising as Left Ventricular Pseudoaneurysm in a Toddler

Spontaneous fatal cardiac tamponade- A case series at VMMC & SJH, New Delhi

Cardiac Tamponade (CT) is a dangerous medical state which is a fatal emergency that requires rapid medical attention to reduce the high risk of death. Accumulation of the fluid inside the pericardial space lowers cardiac filling, as well as blood pressure; resulting in cardiogenic shock leading to sudden death. Sudden death can also happen due to many reasons, including Cardiac Tamponade, which happens without warning and with a wide range of clinical presentations and diagnoses made at post-mortem examination. Common highlights such as already known aortic aneurysm, old age, male sex, and beatless electrical movement also increment doubt of the Cardiac Tamponade. Previous research has linked cardiac tamponade to a variety of other clinical disorders, including cancer, open-heart surgery, central venous catheterization, myocardial abscess, dissecting aortic aneurysm, infective endocarditic, etc. However, death caused by Cardiac Tamponade remains unknown and suspected until a postmortem examination is conducted. In this study, a series of eight cases of Cardiac Tamponade have been included, whose death was sudden and unexpected and examined in the mortuary of Vardhman Mahavir Medical College (VMMC) & Safdarjung hospital, New Delhi and conclude the cause of death as Cardiac Tamponade. In the present study, the authors also reported sudden and unexpected death in healthy males and females caused by Cardiac Tamponade and focused the study towards autopsy examination, and post mortem findings.

Infective endocarditis in children: A 10-year multicentric study

Congenital heart disease (CHD) represents a predisposing condition for the development of infective endocarditis (IE). In recent years, the reduction in the incidence of rheumatic heart disease, advances in cardiac surgery and the increased use of long-term central venous catheters in subjects without CHD have changed significantly the epidemiology of the disease. We sought to evaluate the epidemiology of EI in children in the north of France. We retrospectively included all children < 18 years hospitalized for EI in 2008–2018 in 4 tertiary centres. Demographic, underlying conditions, echocardiography, microbiology and outcomes were collected. We identified 64 episodes of IE in 60 children. Incidence was 3.07 cases for 10,000 paediatric hospitalisations ( Table 1 ). Median age was 8 years [0–13] and distribution was bimodal with peaks in infancy and adolescence. An organism pathogen was isolated in 87.5% of cases. The most common was Staphylococcus aureus (34%), then streptococcus (25%). At echocardiography, anomalies were vegetations ( n = 32), new valvular regurgitations ( n = 10), peri-valvular abscesses ( n = 2). Among cohort, 45 had a CHD (70%), 7 were preterm birth (11%), 2 had long-term central venous catheters and 10 no predisposition. No CHD group was significatively younger than CHD group. Among CHD patients, 38 (84%) had previous heart surgery and 10 presented an IE < 2 months after surgery. Pulmonary bioprosthetic valve were involved in 22 cases and mechanical valve in 3. Cardiac surgery was needed in 26 cases (41%) including valve replacement in half of them and were significatively higher in CHD group ( P < 0.05). Complications of IE occurred in 35 (58%) including emboli, mycotic aneurysm, cerebral haemorrhage and myocardial abscess. IE mostly occurred in predisposed children. Morbidity is important with neurological impairment and valvular replacement in this young population at risk for recurrence.

Emphysematous myocardial abscess without infective endocarditis.

Diagnosis of myocardial abscess without endocarditis is challenging, and a high index of clinical suspicion is fundamental for diagnosis. It should never be ruled out before TEE. And CT could be a helpful modality in case of emphysematous morphology.

Right Ventricular Cardiac Abscess Secondary to Traumatic Osteomyelitis

Background: A cardiac abscess is a suppurative infection involving cardiac tissues as myocardium, endocardium, and valves (native or prosthetic). The abscess could form as a direct extension of a preexisting cardiac focus such as bacterial endocarditis or from a distant septic focus leading to bacteremia. Clinical Description: We report an immunocompetent 3-year-old-child with a structurally normal heart presenting in septic shock secondary to right ventricle (RV) myocardial abscess. The abscess developed following hematogenous spread from neglected posttraumatic osteomyelitis of the left ankle and the causative organism was identified as methicillin sensitive Staphylococcus aureus. Management: Prompt action by a multidisciplinary team helped in reaching the diagnosis, effective management of septic shock, emergency open heart surgical removal of the septic mass, and concomitant lower limb arthrotomy saved the child from a bad outcome. Conclusion: This case reiterates the need for aggressive treatment of the open skeletal wound to prevent bacteremia and complications such as myocardial abscess. In a child presenting in septic shock, a quick point-of-care echocardiography is critical in ruling out possible underlying cardiac conditions such as bacterial endocarditis, myocardial abscess, or pericardial effusion. A high index of clinical suspicion is required to make a prompt diagnosis and aggressive medical and surgical intervention for good outcomes.

Interpreting troponin elevation in the setting of infective endocarditis: Causes and prognostic value

Measurement of cardiac troponin (cTn) levels in blood is standard for diagnosis and risk stratification in cardiac emergencies. To investigate the causes, link to underlying coronary artery disease and prognostic value of cTn release in infective endocarditis (IE). Eighty-six consecutive patients hospitalized for acute IE, with at least one cTn drawn and a coronary angiogram performed, were reviewed retrospectively. Factors related to the increase of cTn above the 99th percentile or above 10 times normal (> 10N), as well as their prognostic impact, were assessed. The mean patient age was 63 + 14 years, the majority were men (n = 68, 79%) with staphylococcus IE (n = 34, 40%). Cardiac troponins were elevated above the 99th percentile for 74 (86%) patients and > 10N for 25 (29%) patients. There was no statistically significant correlation between elevated cTn and the presence of an underlying coronary artery disease (Table 1). Cardiac troponin elevation above the 99th percentile was significantly associated with impaired renal function (P = 0.04) and staphylococcus infection (P = 0.02). A rise of cTn > 10N was significantly associated with acute pulmonary edema (P = 0.001), myocardial abscess (P = 0.01), staphylococcus (P = 0.0004), streptococcus (P = 0.008), and renal function (p = 0.0001). The average follow-up period was 919±816 days, and an elevation of cTn > 10 N had a clear prognostic impact (HR 2.38, 95%CI: 1.18–4.84, P = 0.01) (Fig. 1). Troponin elevation in IE is frequent and appears to be related to direct and indirect myocardial injury. It is associated with a poor prognosis.

An update on joint ill in sheep.

This focus article has been prepared by Vanessa Swinson of the APHA Small Ruminant Expert Group.

Successful Management of a Giant Mycotic Coronary Artery Aneurysm Develeped after Multivessel PCI with Drug-Eluting Stent

Coronary artery stent infection has been reported with both bare metal stent and drug eluting stent and can present as mycotic coronary artery aneurysm, pseudoaneurysm. myocardial abscess, pericarditis or exudative effusion. Infection at the site of coronary stent implantation is rare and is believed to result typically from either direct stent contamination at the time of delivery or transient bacteraemia from access site. Recently, several case reports of pseudoaneurysm formation after DES implantation have been reported in the literature. We describe the successful surgical management of giant mycotic pseudoaneurysm of RCA presenting as fever of unknown origin with AMI (inferior) three months after multivessel PCI in LAD &amp; RCA with DES in radial route. This report illustrates the importance of early detection and prompt management of these rare coronary pseudoaneurysms, which is a highly lethal condition. At three months follow-up after surgery, the patient was asymptomatic with fair LVEF 58%&#x0D; Bangladesh Heart Journal 2020; 35(1) : 66-70

Successful treatment of Aspergillus mural endocarditis in malignant lymphoma using a combined antifungal and surgical approach: a case report

BackgroundAspergillus endocarditis (AE) is a rare and lethal cardiac infection with a high rate of mortality. AE most commonly presents in immunocompromised patients and is associated with various co-morbidities. Herein, we present a case of AE associated with lung, brain, and cervical abscesses after chemotherapy for malignant lymphoma that was successfully treated by a combination of antifungal and surgical therapy.Case presentationA 29-year-old man was admitted to our hospital with an unidentified fever. He was diagnosed with malignant lymphoma (extra-nodal NK/T cell lymphoma nasal type), and chemotherapy was administered. After chemotherapy, nodular lung shadows along with new brain, cervical, and myocardial abscesses appeared, despite anti-bacterial/fungal therapy. Gene analysis of the cervical abscess biopsy revealed the presence of Aspergillus fumigatus species, and the transesophageal echocardiogram showed a mobile mural vegetation in the left ventricle (22 × 8 mm). He underwent surgical resection of this mural vegetation. His postoperative course was uneventful. He remains healthy at 28 months after surgery with continued oral antifungal therapy.ConclusionAlthough AE associated with immunosuppression is a fatal clinical presentation, combined treatment with surgical resection and antifungal therapy was effective.

Infective endocarditis in children: A 10-year multicentric study

Congenital heart disease (CHD) represents a predisposing condition for the development of infective endocarditis (IE). In recent years, the reduction in the incidence of rheumatic heart disease, advances in cardiac surgery and the increased use of long-term central venous catheters (CVC) in subjects without CHD have changed significantly the epidemiology of the disease. We sought to evaluate the epidemiology of IE in children in the north of France. We retrospectively included all children < 18 years hospitalised for IE in 2008-2018 in 4 tertiary centres. Demographic, underlying conditions, echocardiography, microbiology and outcomes were collected. We identified 64 episodes of IE in 60 children. Incidence was 3,07/10 000 paediatric hospitalisations. Median age was 8 years [0–13] and distribution was bimodal with peaks in infancy and adolescence. An organism pathogen was isolated in 87% of cases. The most common was Staphylococcus aureus (34%) then streptococcus (25%). At echocardiography, anomalies were vegetations ( n = 32), new valvular regurgitations ( n = 10), peri valvular abscesses ( n = 2). Among cohort, 45 had a CHD (70%), 7 were pre-term birth (11%), 2 had long-term CVCs and 10 no predisposition. Non-CHD patients were significantly younger than CHD patients ( Table 1 ). Anomalies at echocardiography and identification of pathogen were more common in non-CHD patients. Among CHD patients, 38 (84%) had previous heart surgery and 10 presented an IE < 2 months after surgery. Pulmonary bioprosthetic valve were involved in 22 cases and mechanical valve in three. Cardiac surgery was needed in 26 cases (41%) including valve replacement in half of them. Complications of IE occurred in 35 (58%) including emboli, mycotic aneurysm, cerebral haemorrhage and myocardial abscess. IE mostly occurred in predisposed children. IE in CHD and non-CHD patients has different features, diagnosis is more arduous and needs more investigation as nuclear medicine imaging.

P181 An uncommon mechanism of severe mitral regurgitation due to infective endocarditis mimicking acute myocardial infarction

Abstract A 53-year-old man, smoker, with diabetes mellitus, presented to the Emergency Department because of intense chest and abdominal pain, accompanied by dyspnea and high fever (39.5 °C) in the previous 4 days. Physical examination revealed an apical holosystolic murmur, with no signs of peripheral or pulmonary edema. An ECG showed sinus rhythm (90 bpm), complete right bundle branch block and minimal ST elevation in the inferior leads. A transthoracic echocardiography showed a mild reduction in left ventricle ejection fraction (EF 44%) due to akinesia of the infero-lateral wall, and mild mitral regurgitation (MR) due to mitral valve prolapse. An abdominal ultrasound ruled out signs of acute cholecystitis. Blood cultures were collected, and an empirical antibiotic therapy was started. Urgent blood exam showed high Troponin I (72000 ng/L) and high C-reactive protein (290 mg/L). An acute coronary syndrome was suspected based on clinical, ECG and echocardiography exam, and the patient underwent coronary angiography (Figure 1, Panel A) that showed no significant coronary stenosis, except for two small filling defects in the very distal part of both the left anterior descendent and the circumflex coronary arteries suspected for coronary emboli. The patient was then admitted in the coronary care unit, but after just a few hours his clinical and hemodynamic condition deteriorated. A transesophageal echocardiography was performed to rule out mechanical complications related to the acute myocardial infarction and revealed severe MR (Panel D), elongated, hyperechogenic and dysfunctioning antero-lateral papillary muscle (ALPM) with an abnormal mobility suggestive for myocardial abscess, and a mobile mass attached on the aortic valve suggestive for vegetation (Panel B and C). Due to the worsening hemodynamic status, the patient underwent urgent cardiac surgery. Histological analysis confirmed the presence of an abscess of the ALPM due to Staphylococcus Aureus. The patient died after a week because of cerebral hemorrhage. Autopsy reported multiple lungs, renal and cerebral embolic septic infarctions. Learning points coronary artery embolization and papillary muscle abscess are very rare and often fatal consequences of infective endocarditis (IE). High (otherwise unexplained) fever and signs of embolism are minor Duke modified criteria for IE that should lead the physician to look for major criteria, such as positive blood cultures or echocardiography suggestive for IE. Emboli seen in the very distal part of the coronary arteries might have caused the ALPM abscess. Abstract P181 Figure

Acute type A aortic dissection - a case beyond the guidelines

Introduction. There are not many cases among acute type-A aortic dissection survivors who get to be called ?incredible.? Here we present such a case followed-up for more than five years. Case outline. A 48-year-old male with acute type A aortic dissection, complicated with cardiac tamponade and severe aortic valve regurgitation, was submitted to emergent surgical treatment. Distal reconstruction was performed by complete aortic arch replacement with ?elephant trunk? extension and separate arch branch bypasses, while the proximal reconstruction was done with Bentall procedure. Total of 11 anastomoses was necessary to complete this procedure. Straight profound hypothermic (18o C) circulatory arrest, with a saturation of the venous blood from the jugular bulb of 97%, lasted 133 minutes. The patient was discharged stable without any neuro-cognitive deficit. Two years later, he was admitted with late prosthetic valve endocarditis and subvalvular abscess. Good response on treatment with efficient combined antibiotics and stabile hemodynamic allowed us to avoid barely feasible re-do surgery. Subvalvular myocardial abscesses evolved into periprosthetic pseudoaneurysms without infectious, thrombo-embolic, or hemodynamic deterioration. The patient is still alive and stable, more than four years after this event. Conclusion. Fortunate outcome of these life-threatening conditions is a reason to reconsider our understanding of cerebral function and metabolism during the profound hypothermic circulatory arrest, and it emphasizes the importance of measuring individual patient response against disease treatment guidelines, as we did, treating the late, complicated prosthetic valve endocarditis with medicaments, instead of high-risk surgery.