Case presentation
A 23-year-old female presented with one month history of intermittent
high grade fever, associated with lethargy and weight loss (2kg in three
weeks).
There was no history of chest pain, hemoptysis, and dyspnea at rest.
There was history of recent dental intervention.
On examination, she was febrile and cachectic, with marked conjunctival
pallor. There was a continuous murmur, with a thrill over the pulmonary
area.
There were no other stigmas of infective endocarditis.
A chest X-ray was unremarkable.
On physical examination, TA was 120/80, heart rate 100, body temperature
was 38,5 °C.
Auscultation revealed a continuous murmur in left 2nd intercostal space.
Laboratory workup showed C-reactive protein 100mg/L, leukocytes
12,000/mm3, hemoglobin 8.5 g/dL
Two consecutive blood were positive for streptococcis viridans.
Transthoracic echocardiography revealed a large PDA (10mm) with left to
right shunt, and a fixed structure on the wall of the pulmonary artery
with erratic movement indicative of a vegetation (Figure 1) and mobile
vegetation attached to the wall of the descending aorta in the supra
sternal view (Figure 2), a left ventricle with conserved systolic
function and 55mm end-diastolic diameter
Computed tomography (CT) scan showed two mycotic pseudoaneurysms of the
descending aorta (Figure 3).
Following three days of antibiotic treatment (ampicillin and
gentamycin), she had symptomatic improvement and became afebrile.
A repeat echocardiography did show a disparition of the pulmonary
vegetation, a repeated CT scann showed no embolism to the pulmonary
trunk.
Decision was made for surgical intervention.
After establishment of a femoro femoral partial by-pass. The thorax was
entered through the left fourth intercostal space. Two juxta- ductal
aneurysmal formations with inflammatory adhesions were found (Figure 4).
The proximal clamp was placed across the left subclavian artery and the
distal clamp inferior to the false aneurysms site. The ductus arteriosus
was initially clamped.
The descending aorta was opened, we proceeded to debridement of the
infected aorta from the vegetations and we decided to close the false
aneurysms by direct sutures (Figure 5).
We then proceeded to a section suture of the patent ductus arteriosus.
Postoperative course was uneventful.
Patient was discharged home after two weeks, she was asymptomatic at
3-months of follow-up.