Multivalve Endocarditis and Aortic Root Abscess with Associated Rupture of Sinus of Valsalva due to Streptococcus pneumoniae Rebecca B. Lee, DO 1 , Matthew T. Perkins, MD 1 , Ankur Lodha, MD 2 1. Louisiana State University Health Sciences Center 2 . Cardiovascular Institute of the South Introduction: Infective endocarditis (IE) as a consequence of Streptococcus pneumoniae bacteremia is uncommon. Aortic root abscess can also be associated with IE but is seldom seen. Sinus of Valsalva (SOV) rupture due to aortic root abscess is exceedingly rare. We present a case of multivalve IE and aortic root abscess with associated rupture of the SOV due to Streptococcus pneumoniae . Case Report: A 43-year-old African-American male with a past medical history of polysubstance abuse and type 2 diabetes was admitted to an outside hospital after being found down in his home. Electrocardiogram on arrival was significant for sinus tachycardia and first-degree atrioventricular block. He was noted to be incoherent but responsive. Urine drug screen was positive for cocaine and marijuana. He was empirically treated with vancomycin and cefepime. Initial laboratory evaluation revealed acute kidney injury, elevated liver enzymes, and elevated troponin levels. Transthoracic echocardiogram was performed and showed moderate to severe aortic regurgitation (AR). The patient was then transferred to our facility for presumed IE requiring cardiothoracic surgery intervention. At our facility, the patient underwent transesophageal echocardiogram (TEE). TEE revealed a large vegetation on the aortic valve and an aortic root abscess with SOV rupture with flow into the right atrium. AR was noted to be severe. There was also a small vegetation noted on the tricuspid valve leaflet with associated moderate tricuspid regurgitation. Blood cultures were ultimately positive for Streptococcus pneumoniae . The patient continued to deteriorate, requiring transfer to the intensive care unit and intubation for airway support. He required pressor support and was no longer considered a viable candidate for aortic root surgery. The family decided to change his status to “do not resuscitate” and he passed shortly after. Discussion: IE due to Streptococcus pneumoniae is a very rare cause of IE and accounts for less than 1% of cases 1 . Aortic root abscess is a severe complication of IE which carries a high fatality rate. Rupture of the SOV is an exceedingly rare complication of IE and aortic root abscess 2 . Intervention and repair is required to ensure patient survival. In those who are stable enough to undergo intervention, surgical repair is indicated for ruptured SOV aneurysms 3 . References: 1. Egea, V. D., Muñoz, P., Valerio, M., Alarcón, A. D., Lepe, J. A., Miró, J. M., . . . Bouza, E. (2015). Characteristics and Outcome of Streptococcus pneumoniae Endocarditis in the XXI Century. Medicine,94 (39). doi:10.1097/md.0000000000001562 2. Ali, A. M., Waseem, G. R., & Arif, S. (2018). Endocarditis due to Aortic Root Abscess in a Patient with Rupture of Sinus of Valsalva. Journal of Microbiology and Infectious Diseases, 69-72. doi: 10.5799/jmid.434597 3. Weinreich, M., Yu, P., & Trost, B. (2015). Sinus of Valsalva Aneurysms: Review of the Literature and an Update on Management. Clinical Cardiology,38 (3), 185-189. doi:10.1002/clc.22359
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