We describe the case of a 40-year-old male patient with a history of valve replacement by bioprosthesis in the mitral position two years before the current disease due to stenosis secondary to rheumatic fever.
Established on November 9, 2000, a two-week history of sudden dyspnea after intense physical activity, accompanied by orthopnea and hemoptysis.
On physical examination at admission, a patient was in regular general condition with the following vital signs: blood pressure 120 mmHg and heart rate 109 93% beats per minute, respiratory rate 28 per minute, temperature 93% C
Pulmonary auscultation revealed biphasic crepitations and cardiac noises were rhythmic without murmurs, with splitting of the second sound.
There were no relevant findings when examining the abdomen or extremities.
The initial laboratory tests showed a white blood cell count of 20,300 with 84.4% neutrophils and 9.8% lymphocytes, hemoglobin of 12.9 mg/dl, hematocrit of 39.8% and platelet count negative erythrocyte sedimentation rate of 11mg/dl.
She was hospitalized with the diagnosis of acute pulmonary edema secondary to prosthetic mitral valve dysfunction.
Among the possible causes, infective endocarditis was considered due to the significant increase in acute phase reactants.
Samples for hemocultives were taken immediately; given the severity of the clinical picture, it was decided to start empirical treatment for late prosthetic infective endocarditis with oxacillin (12 g per day, intravenous infusion of nitroglycerin (160 hours), ampicillin with intravenous infusion of IV)
An urgent transthoracic echocardiography was performed, which showed a large vegetation in the mitral bioprosthesis, so it was agreed with the cardiovascular surgery group an early surgical management.
However, on the second day of hospitalization the patient presented sudden deterioration of his clinical condition.
A new echocardiogram showed complete valve obstruction and therefore required surgery under urgent cardiopulmonary bypass, in which bioprosthesis was replaced by a mechanical valve (Carbomedics® No 31 mm).
Upon removal of the previous valve, multiple vegetating lesions were observed, larger than 3 cm in diameter, in the periphery and lumen of the prosthesis, which were sent for histopathological analysis and culture.
Conventional surgery was completed and the patient was transferred to the cardiovascular intensive care unit for postoperative monitoring and management.
The subsequent evolution was satisfactory: it was possible to disassemble the inotropic and vasopressor support quickly, as well as the respiratory support.
Blood cultures (six samples) taken on the day of admission were reported as negative.
Histopathological analysis of the vegetation adhered to the valve prosthesis and obtained during surgery reported a compact fibrin mass with abundant polymorphonuclear infiltrate, macrophages and cellular detritus.
Microscopic examination with lactophenol blue showed hyaline hyaline phases of the wall with irregular appearance and irregular appearance, branching to hyalica with various branches, with sentiform chains that formed not 8 μlip
1.
This finding was confirmed by culture that reported the presence of P. variotii.
After obtaining this information and after reviewing the pyogenic cultures of the surgical sample, which were reported as negative, antibiotics were suspended and amphotericin B was started (1.5 mg/kg as a total daily dose), until completing 3.6 g.
Treatment-related complications were hypokalaemia and tubulointerstitial nephritis reversible.
Symptomatic valve stenosis persists in New York Heart valve function. The patient was started in an outpatient clinic where cardiac rehabilitation therapy was not performed and was discharged for periodic monitoring after reaching a 3.6 g dose of amphotericin B.
