A 49-year-old male, with no known morbid history, who consulted for a febrile syndrome of 7 days of evolution, associated with pleurisy pain, cough and expectoration, which was an acute attack of dyspnea.
The evaluation of the patient showed great compromise of general status, Glasgow scale 11, poor ventilatory mechanics, hypertension with 170/90 mmHg, regular tachycardia of 130 bpm, fever with 38.3 °C, focal stiffness of 2 seconds and focal neurological examination.
Due to the compromise, he was connected to mechanical ventilation, starting sepsis management.
Tests were performed, including hemocultives, non-contrast-enhanced computed axial tomography (CAT) of the brain that showed no structural changes and chest CT where multiple images of alveolar consolidation were observed in both lung fields.
Cerebrospinal fluid analysis, which was cloudy, with hypoglycorrhachia of 1 mg/dl, leukocytes of 3,120 mm3 with 100% polymorphonuclear, and Gram-small spectroscopic treatment with levofloxacin Gram-positive bacteria first antibiotic leukocytosis Gram-positive, began with leukocytosis 12 h.
Laboratory tests showed leukocytosis of 18,700 mm3 with predominance of neutrophils with 17,780 mm3, without anemia, platelets, renal function, liver function and normal plasma electrolytes, high C-reactive protein 28 mg/dL, bicarbonate 48 mmol/dL
S. pneumoniae was isolated in 2 peripheral hemocultives and in the culture of the cerebrospinal fluid, with MIC of 0.03 and 0.016 for penicillin G and cephalosporins, respectively, in both samples, antibiotic treatment was initiated day 4
The results of the examinations were compatible with a systemic bacterial infection with a meningeal and pulmonary focus caused by S. pneumoniae, without apparent anatomical lesions.
The patient remained seated in good general conditions, with recovery of respiratory function, was deconnected from mechanical ventilation at 3 days, however, persisted with feverish rises and high differential blood pressure.
The patient was reassessed and the presence of a diastolic murmur in aortic focus of intensity III/IV, aspiration was found.
A transthoracic echocardiogram showed cardiac cavities of conserved size, left ventricle with preserved systolic and diastolic function and image highly suggestive of vegetation in the aortic valve on the basis of the right coronary velum 1 cm long aortic regurgitation, mobile.
Two days later, a preoperative transesophageal echocardiogram was performed, which corroborated the findings consistent with endocarditis, describing tricuspid aortic valve and in the right coronary velum identified nodular lesion pedunculated reflux of 9 mm of greater diameter and no perlegular abscess, compatible with perlegular perforation.
The left ventricle was dilated, with a final diastole diameter of 58 mm, with preserved systolic function, while the normal mitral valve was described as tricuspid regurgitation without vegetations, with mild central cavity reflux,
In this context, cardiac surgery for aortic valve replacement was performed 8 days after admission to the hospital, maintaining treatment with penicillin after one week of antibiotic coverage.
Aortic valve replacement was performed with St Jude A19 mechanical valve; in the macr, an aortic valve was observed with a perforated right velum and a vegetation of 8 mm in length.
Culture of the valve tissue was negative and biopsy showed inflammatory degeneration.
The patient was treated conservatively, completing 28 days of antibiotic treatment with intra-treatment cultures at 21 negative days, so he was discharged with outpatient control.
