A 63-year-old woman with a history of hypothyroidism (right post-hemityroidectomy due to Plummer's disease), primary hypoparathyroidism (total thyroidectomy and parathyroidectomy), currently diagnosed with aortic valve smoking (20 cigarettes).
She presented dyspnea functional class III (New York Heart Association functional classification), aggravated by episodes of nocturnal paroxysmal dyspnea of two weeks of evolution, progression of edema in lower extremities and unquantified fever.
Physical examination revealed tachypnea with oxyhemoglobin saturation 94% with ambient air, heart rate 98 beats per min, and blood pressure 110/70 mmHg.
Pulmonary examination revealed crypts in up to one third of both lung fields, jugular engorgement, and lower limb edema.
Cardiac examination revealed normal heart sounds with an aortic systolic murmur of 3/6 intensity.
The admission laboratory showed hyponatremia (130 mmol/l), normal potassium and chlorine levels, white blood cell count 9,500 cells/mm3, neutrophils 91%, hemoglobin 10.8 g/dl, a C-reactive protein of 2.8 mg/dl and no
Coronary artery disease was hospitalized due to cardiac failure.
Treatment with vasodilators and diuretics was initiated with good initial response.
Coronary angiography showed coronary arteries without significant lesions.
During her first day of hospitalization she presented fever 38.5 °C, without hemodynamic instability.
Two hemocultives and urocultives were taken and treatment was initiated with antimicrobials (piperacillin-silica, 4.5 g, every 1,000, and vancomycin 1 g, every 12 h), in addition to a continuous infusion.
At 48 h, positive blood cultures for gram-positive cocci were reported.
Subsequently, the colony was identified by MALDI-TOF MS as Abiotrophia defectiva, so antimicrobial therapy was changed to intravenous ampicillin 2 g, four times a day, plus gentamicin 8 kg.
A transesophageal echocardiogram showed a bicuspid aortic valve intensely thickened with a vegetation of 9 mm associated with a cavity of 1.5 x 1.5 cm in the posterior diastolic abscess ascending aorta shunt with fibrous aortic outflow.
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With these elements, surgery with valve replacement was decided.
Intraoperative findings showed inflammatory tissue with multiple vegetations on the aortic valve.
A valvectomy and decalcification of the ring were performed.
An annular cavity corresponding to an abscess drained spontaneously was observed in the region of the non-coronary valve.
Curettage and profuse washing were performed.
A St Jude N° 21 mechanical prosthesis was placed.
The valve was sent to culture, without obtaining microbiological development probably because the patient was under antibacterial treatment at the time of surgery.
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Due to renal failure secondary to drugs, ampicillin and gentamicin were changed to vancomycin.
A dose of 1 g was administered every 12 h.
Adequate plasma levels of vancomycin were managed in nadir (15.4 ug/dl), with no change in renal function.
The patient completed antimicrobial treatment for a total of four weeks, with a favorable clinical evolution.
