A Silent Heart Break: An Uncommon Case of Silent Mitral Valve Perforation Secondary to Infective Endocarditis

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Introduction: Infective Endocarditis (IE) is an endocardial surface infection of the heart which may lead to valve damage and if severe, this may even lead to valve perforation which can cause significant regurgitation and cardiac function compromise. We present an uncommon case of IE complicated by mitral valve perforation.

Case presentation: A 46-year old male with AIDS and polysubstance use was brought to the ED from a shelter after exhibiting erratic behavior with confusion. On exam, he was febrile and tachycardic. Lab data pertinent for lacticaemia and leukocytosis. Blood cultures grew Streptococcus Pneumoniae. MRI Brain was unremarkable. Echocardiography was unremarkable. Antibiotic was initiated leading to marked improvement in patient’s mental status. Despite clinical improvement, days into hospital course, a new holosystolic murmur was audible with left axillary radiation necessitating a repeat echocardiogram which revealed moderate-to-severe mitral eccentric jet regurgitation concerning for anterior leaflet perforation. He remained euvolemic without symptoms of heart failure and was subsequently transferred to a tertiary facility where a mitral valve surgery replacement was scheduled.

Discussion: Most patients with infective endocarditis have no preceding valvular abnormality. This case is unusual as there was valvular perforation with no evidence of valvular involvement on prior imaging which could possibly be as a result of invasive streptococcus pneumonia IE potentially coexisting with bacterial meningitis which carries a high mortality rate. Invasive streptococcus pneumonia is an unusual cause of IE since wide availability of antibiotics and vaccines. This case reminds us of the need of thorough physical exam and sequential imaging in such immunocompromised patient groups.

Conclusions: A high suspicion for mitral valve perforation should be maintained in patients with invasive streptococcus pneumoniae and new cardiac murmur.




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American Heart Association Scientific Sessions, November 11-13, 2023, Philadelphia, PA