INVESTIGATION
The patient’s blood work showed leukocytosis, normocytic anemia,
elevated creatinine, and the presence of RBCs, nitrites, and proteins on
urinalysis. A chest X-ray ruled out any lung pathologies. A CT chest
(Figure 2B) , abdomen and pelvis ruled out renal or pulmonary
pathologies and was started on Ceftriaxone 1g IV. Initial blood culture
revealed gram-positive cocci for which Piperacillin-Tazobactam 3.375g
q6h IV (Pip-Tazo) was added to the treatment. Subsequently, the blood
cultures showed Methicillin Sensitive Staph Aureus (MSSA) bacteremia and
therapy was changed to Vancomycin 2g IV loading dose followed by 1250mg
IV q12h and Cefazolin 2g IVq8h. The patient had a transthoracic
echocardiogram (TTE) which demonstrated moderate aortic regurgitation
and severe aortic stenosis with bi-atrial enlargement. However, the
transesophageal echocardiography (TEE) showed a well loculated large
area of echo-dense material around the aortic valve consistent with a
peri-aortic abscess (Figure 2A) with no evidence of
endocarditis. Cardiac catheterization was normal.