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Ultrasound Corner |

Fever in a Young Female: Unmasking a Rare Disaster FREE TO VIEW

Ayman Elbadawi, MD; Yasser Alaa, MD, PhD; Hany Foad, MD, PhD; Marwan Saad, MD, PhD
Author and Funding Information

aDepartment of Medicine, Rochester General Hospital, Rochester, NY

bDepartment of Cardiovascular Diseases, Ain Shams Medical School, Cairo, Egypt

cDepartment of Medicine, Division of Cardiovascular Diseases, University of Arkansas for Medical Sciences, Little Rock, AR

CORRESPONDENCE TO: Ayman Elbadawi, MD, Department of Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621


Copyright 2016, . All Rights Reserved.


Chest. 2016;150(3):e77-e79. doi:10.1016/j.chest.2016.03.065
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Published online

A 24-year-old woman was evaluated in our ED for 2 weeks’ duration of subjective fevers, chills, and generalized fatigue. Her history is significant for intravenous (IV) drug abuse. Review of systems did not reveal any other symptoms such as chest pain, shortness of breath, or headaches. On presentation, she had blood pressure of 124/62, heart rate of 97 beats/min, respiratory rate of 18 breaths/min, and oral temperature of 100.2°F. Pulse oximetry was 97% on room air. Physical examination was unremarkable. Electrocardiogram was normal. Chest radiography showed normal cardiac silhouette with normal lung fields. Laboratory workup showed an erythrocyte sedimentation rate of 38 mm/h, a C-reactive protein of 105 mg/L, and total leukocytic count of 14,000/mm3. Blood culture was drawn, and broad-spectrum antibiotics were administered. Given her history of IV drug abuse, we proceeded to a two-dimensional transthoracic echocardiogram (TTE) to rule out infective endocarditis.

Video 1 Shows TTE examination with apical four-chamber view (clip 1), parasternal long axis view (clip 2), and parasternal short-axis view (clip 3).

Question: Based on Video 1 and the patient’s clinical history and physical examination, what is the most likely diagnosis?

Answer: Aortic root abscess

TTE showed a well-circumscribed homogenous echo-dense mass in the posterior aortic wall suggestive of aortic root abscess. All valves were of normal morphology and normal flow. Trans-esophageal echocardiogram (TEE) was subsequently done. Video 2 shows long-axis view of aortic valve (clip 4) and short-axis view of aortic valve (clip 5) confirming the aortic root abscess with absence of any associated valvular abnormality.

The patient refused surgical intervention. By the third day of her hospital course, her blood culture grew Staphylococcus epidermidis, and antibiotics were adjusted based on culture sensitivity. Unfortunately, and despite extensive discussion with the patient about her condition, she left the hospital against medical advice and failed to follow-up.

We present a rare case of infective endocarditis (IEC) in the form of isolated aortic root abscess without any valvular affection secondary to IV drug abuse. The establishment of IEC diagnosis mandated an initial suspicion index based on her presentation and history of IV drug abuse, and was confirmed with TTE, TEE, and the presence of bacteremia (Video 3).

Video 1 shows TTE examination; in clip 1, we see apical an four-chamber view that showed normal flow, normal morphology, and absence of any vegetation in both mitral and tricuspid valves. It also showed normal left ventricular contractility and no pericardial effusion. In clip 2, we see parasternal long-axis view, which illustrated the normal valvular morphology and absence of any vegetation in both mitral and aortic valves. Figure 1 shows parasternal long axis view of the patient in our study (left image), compared to that of a normal subject (right image). However, interestingly we see an echo-dense homogenous mass at the posterior aortic wall. Parasternal short-axis view at aortic valve level was demonstrated in clip 3, in which we see the homogenous mass in posterior aortic wall (Fig 2). In clip 3, we can also see normal valvular appearance and normal blood flow in both aortic and pulmonary valves (mild physiologic pulmonary regurgitation is appreciated in pulmonary valve though). An echo-dense mass with such appearance in this clinical setting was suggestive of aortic root abscess.

Figure 1
Figure Jump LinkFigure 1 Left image shows PLAX view in the patient in our study, with aortic abscess seen in posterior aortic wall. Right image shows normal PLAX view in another normal subject. Ao = aorta; LA = left atrium; LV = left ventricle; PLAX = parasternal long axis.Grahic Jump Location
Figure 2
Figure Jump LinkFigure 2 Left image shows PSAX view in the patient in our study, with aortic abscess seen in posterior aortic wall. Right image shows normal PSAX view in another normal subject. PSAX = parasternal short axis; RA = right atrium. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location

The sensitivity of TTE for diagnosis of aortic root abscess is nearly 50%, whereas sensitivity of TEE is 90%, but specificity is more than 90% for both TTE and TEE. The diagnosis is easy in the presence of a clear free space in the aortic root, but may be much more difficult at the early stage of the disease when only a thickening of the aortic root is observed. TEE is recommended even in cases of positive TTE because of its better image quality and better sensitivity particularly for perivalvular involvement; hence, we proceeded to TEE examination.

In Video 2, we see the TEE examination. In clip 4, we see long-axis view of aortic valve, which helped to better evaluate the mass; it appeared as a well-circumscribed homogenous echo-dense mass without color flow inside, meeting the echocardiographic definition of an abscess. The mass was located in posterior aortic extending inferiorly into the left ventricular outflow tract below the aortic valve ring. Superiorly, it was limited by a sino-tubular junction with no extension to the ascending aorta. We can clearly see the aortic valve with no structural involvement and absence of stenosis or regurgitation across the valve. TEE examination with a short-axis view of the aortic valve is shown in clip 5, which confirmed previous findings of normal aortic valve and characterized the abscess to be related to both left and noncoronary cusps. Further TEE study showed no encroachment on coronary ostia by the abscess.

The alternative differentials for such a mass included aneurysm of the sinus of Valsalva or a dissecting aneurysm of ascending aorta. An aneurysm of sinus of Valsalva tends to have a “wind sock” appearance, described as a long sac of mobile tissue projecting into adjacent structures, which is not present in our case. The absence of ascending aorta involvement together with the clinical presentation made dissecting aneurysm unlikely.

The reported incidence of perivalvular abscess among patients with IEC is 30% to 40%., The aortic valve is more susceptible to abscess formation than the mitral valve and usually involve the mitral-aortic intervalvular fibrosa. Secondary involvement of subaortic structures occurs as a result of direct extension of the infection from the aortic valve or as a result of an infected aortic regurgitant jet striking these areas. The interesting feature in our case is that all heart valves had normal flow and morphology with no attached masses. The presence of Aortic root abscess without any evidence of endocarditis on the aortic valve is extremely rare.

Although TEE helped with better characterization of the extent and size of abscess as well as its relation to other structures, mainly the coronary osita; however, pathological evaluation of the mass would have been of great value if the patient in our study agreed to surgical intervention.

  • 1.

    This case highlights the importance of high index of suspicion for infective endocarditis in patients with fever and predisposing factors for bacteremia.

  • 2.

    The importance of TEE in establishing diagnosis of IEC, especially with aortic root involvement.

  • 3.

    Although very rare, aortic root abscess can be the sole echocardiographic sign of IEC, without associated valvular affection.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Zabalgoitia M. .Garcia M. . Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography. 1993;10:203- [PubMed]journal. [CrossRef] [PubMed]
 
Daniel W.G. .Mügge A. .Martin R.P. .et al Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795-800 [PubMed]journal. [CrossRef] [PubMed]
 
Habib G. .Hoen B. .Tornos P. .et al Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 2009;30:2369-2413 [PubMed]journal. [CrossRef] [PubMed]
 
Omari B. .Shapiro S. .Ginzton L. .et al Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest. 1989;96:1273-1279 [PubMed]journal. [CrossRef] [PubMed]
 
Daniel W.G. .Mügge A. .Martin R.P. .et al Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795- [PubMed]journal. [CrossRef] [PubMed]
 
Ellis S.G. .Goldstein J. .Popp R.L. . Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography. J Am Coll Cardiol. 1985;5:647-653 [PubMed]journal. [CrossRef] [PubMed]
 
Rasheed A. .Bu’Lock F.A. .Leanage R. . Aortic root abscess without involvement of the aortic valve in a child caused by Panton-Valentine leukocidin-positive staphylococci. Pediatr Cardiol. 2009;30:349-351 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 Left image shows PLAX view in the patient in our study, with aortic abscess seen in posterior aortic wall. Right image shows normal PLAX view in another normal subject. Ao = aorta; LA = left atrium; LV = left ventricle; PLAX = parasternal long axis.Grahic Jump Location
Figure Jump LinkFigure 2 Left image shows PSAX view in the patient in our study, with aortic abscess seen in posterior aortic wall. Right image shows normal PSAX view in another normal subject. PSAX = parasternal short axis; RA = right atrium. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location

Tables

References

Zabalgoitia M. .Garcia M. . Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography. 1993;10:203- [PubMed]journal. [CrossRef] [PubMed]
 
Daniel W.G. .Mügge A. .Martin R.P. .et al Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795-800 [PubMed]journal. [CrossRef] [PubMed]
 
Habib G. .Hoen B. .Tornos P. .et al Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 2009;30:2369-2413 [PubMed]journal. [CrossRef] [PubMed]
 
Omari B. .Shapiro S. .Ginzton L. .et al Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest. 1989;96:1273-1279 [PubMed]journal. [CrossRef] [PubMed]
 
Daniel W.G. .Mügge A. .Martin R.P. .et al Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795- [PubMed]journal. [CrossRef] [PubMed]
 
Ellis S.G. .Goldstein J. .Popp R.L. . Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography. J Am Coll Cardiol. 1985;5:647-653 [PubMed]journal. [CrossRef] [PubMed]
 
Rasheed A. .Bu’Lock F.A. .Leanage R. . Aortic root abscess without involvement of the aortic valve in a child caused by Panton-Valentine leukocidin-positive staphylococci. Pediatr Cardiol. 2009;30:349-351 [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

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