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CASE 12—2015

Tropheryma Whipplei Endocarditis
Published:February 09, 2015DOI:https://doi.org/10.1053/j.jvca.2014.11.011
      A 50−60-YEAR-OLD MAN with ongoing alcohol and methamphetamine abuse and a suspected history of intravenous drug use presented to the emergency department with a 1-month history of bilateral leg pain. Physical examination was significant for a cold left foot and absent left dorsalis pedis and tibialis posterior pulses. Auscultation revealed a 4/6 crescendo-decrescendo systolic murmur heard loudest over the right upper sternal boarder, and a 3/6 diastolic decrescendo murmur heard loudest over the right lower sternal boarder. Computed tomography angiography confirmed severe bilateral lower extremity peripheral vascular disease. Following tracheal intubation for progressive congestive heart failure, transthoracic echocardiography (TTE) revealed moderate aortic regurgitation and a mass on the aortic valve suggestive of vegetation. The patient went to the operating room for emergent bilateral embolectomies and fasciotomies. Subsequently, he underwent tissue aortic valve replacement with patch reconstruction of aortomitral fibrosa. Intraoperative transesophageal echocardiography (TEE) findings are shown in Figure 1A-D and corresponding TEE clips are available online (Video 1 A-D).
      Figure thumbnail gr1
      Fig 1Intraoperative transesophageal echocardiography (TEE) images before and after aortic valve replacement with patch reconstruction of aortomitral fibrosa. (A) Midesophageal aortic valve long-axis view showing extensive vegetations and entry to a large aortomitral abscess cavity (red arrow). (B) Midesophageal aortic valve long-axis view with color-flow Doppler showing aortic regurgitation. (C) From the perspective of the ascending aorta, a three-dimensional TEE depicts an en face view of the aortic valve. A large vegetation (red arrow) extends into the ascending aorta. (D) Midesophageal aortic valve long-axis view following tissue aortic valve replacement with patch reconstruction of aortomitral fibrosa.

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