Medical history and current illness
- 62 year old woman
- Active life
- No known drug allergies
- Smoker of 0.5 packs of tobacco/day
- Obesity grade 2
- No high blood pressure
- No diabetes
- Hypercholesterolemia
- Hypothyroidism
- Chronic venous insufficiency
- Severe dorso-lumbar scoliosis
- No cardiological history
- Home treatment: lyrica, pitavastatin, furosemide, daflon, voltaren, levothroid

Complementary tests
- Electrocardiogram: sinus rhythm at 70 bpm. Old inferior necrosis. PR 171 msec. QRS 86 msec. QTc 413 msec. Cardiac axis 60o.
- Chest X-ray on admission: cardiomegaly, increased bilateral interstitial tissue with bibasal predominance.
- Blood tests on admission: glucose 150 mg/dl, urea 90 mg/dl, creatinine 3.3 mg/dl, sodium 138 mMol/l, potassium 4.4 mMol/l, INR 1.21, aPTT 25.8, leukocytes 42900/ul, PMN 95.1%, lymphocytes 2000/ul, keys 13%, haemoglobin 9.9 g/dl, haematocrit 30.3%, MCV 88.7, MHC 28.9, platelets 16000/uL.
- Cranial CT scan on admission: poorly demarcated right frontal hypodense lesion.
- Brain MRI: multiple brain lesions with fine annular enhancement and perilesional oedema, the largest measuring 2 cm in diameter, located in the right frontal lobe and both occipital lobes, compatible with brain abscesses.
- Transthoracic echocardiogram on admission: cardiac cavities not dilated. Preserved left ventricular function. Mitral valve with calcification in the posterior annulus, sclerosis and thickening of the posterior leaflet in which a mobile hyperechoic image was observed adhered to the free edge, without being able to rule out vegetation, leading to mild-moderate mitral insufficiency. No other significant valvulopathies. No pericardial effusion.
- Transesophageal echocardiogram on admission: two images were observed at the level of the posterior leaflets (1.4x1.3 cm) and anterior mitral leaflets (0.8x0.9 cm) suggestive of vegetation. Moderate mitral insufficiency.
- Control echocardiogram: colour Doppler image suggestive of perforation of the posterior mitral leaflet. The vegetation in the posterior leaflet was observed to have disappeared. Image in the anterior leaflet suggestive of evolved vegetation. Moderate mitral insufficiency.
- Abdominal ultrasound: medical renal disease with parenchymal scarring. Splenic infarcts. Thrombosis of the celiac trunk.
- Blood cultures on admission: positive for Sth. Aureus sensitive to cloxacillin.
- Control blood cultures: negative.

Clinical evolution
Patient initially admitted to the Intensive Care Unit in septic shock, with acute oliguric renal failure, requiring volume support and vasoactive amines and a brain lesion of uncertain aetiology. There were no septic foci detectable at abdominal level by CT scan, but a transthoracic echocardiogram showed a suspicious image of vegetation on the mitral valve, which was confirmed by transesophageal echocardiogram.
There was also evidence of preserved systolic function and moderate mitral insufficiency. Treated on admission with meropenem, once diagnosed with mitral endocarditis, treatment was started with vancomycin and gentamicin. After the initial blood cultures were positive for cloxacillin-sensitive Sthaphylococcus aureus, the antibiotic regimen was changed to cloxacillin-gentamicin. The study was completed with brain MRI, which confirmed the presence of several lesions compatible with brain abscesses, all of them smaller than 2 cm. After an initial favourable evolution, the patient was transferred to the cardiology ward for further treatment.
On admission to the ward, the patient showed signs of global heart failure, with optimal response to diuretics. In the first few days, she also developed septic embolism in the left lower limb. An urgent transfemoral embolectomy was performed, which was successful. Abdominal ultrasound revealed the presence of several splenic infarctions and an image of an embolus at the level of the celiac trunk (the patient did not present intestinal symptoms at any time), which were not present in the previous abdominal CT scan. Control echocardiograms showed a reduction in the size of the vegetation, persistence of moderate insufficiency, preserved function. Continuing prolonged therapy with cloxacillin for eight weeks, due to the presence of brain abscesses, the patient experienced progressive clinical improvement and improvement of analytical parameters, with disappearance of data suggestive of active infection, normalisation of renal function parameters, remaining afebrile and stable.
The case was discussed in a medical-surgical session, at which time the patient had emboligenic mitral endocarditis with brain abscesses, chronic anaemia, renal insufficiency with GFR around 30 ml/min. Given the high surgical risk and the favourable response to antibiotic treatment, it was decided to continue with medical management, and mitral valve replacement surgery was not ruled out in the event of a progression of the infectious condition.
Once the antibiotic regimen was completed, and given the clinical and haemodynamic stability, discharge home was decided.

Diagnosis
- Endocarditis on native mitral valve, due to Sthaphylococcus aureus sensitive to cloxacillin, emboligenic. Septic shock
- Preserved systolic function. Moderate mitral regurgitation. Perforation of posterior leaflet of mitral valve
- Renal failure of mixed aetiology (nephrotoxic, glomerulonephritis, prerenal)
- Congestive heart failure
- Cerebral septic embolism. Cerebral abscesses smaller than 2 cm
- Femoral arterial septic embolism. Urgent transfemoral embolectomy
- Asymptomatic celiac trunk embolism
- Splenic embolism with infarction
