Background Infective endocarditis (IE) has been reported as a common complication of community acquired S. aureus bacteremia (SAB). Endocarditis cases, however, are most often reported in patients with an underlying cardiac abnormality that serves as a predisposing risk factor, including valve damage from rheumatic heart disease, previous endocarditis, placement of a prosthetic heart valve, or other cardiac abnormalities. There have been reports of isolated cases of community-acquired Staphylococcus aureus leading to endocarditis in a patient with no risk factors.
Case Report A 43-year-old previously healthy Hispanic male presented to the emergency room with a 1-week history of "flu-like " symptoms, multiple petechial hemorrhages present on his abdominal skin, and a 3/6 diastolic murmur in the left parasternal area. Blood cultures grew Staphylococcus aureus in all three blood samples sensitive to nafcillin. Echocardiogram revealed severe aortic regurgitation with possible vegetations. Blood cultures continued to grow Staphylococcus aureus despite intravenous nafcillin and gentamicin. The patient was transferred to tertiary medical center for possible porcine aortic valve replacement but on operation it was found that the left coronary leaflet was completely destroyed with a subannular abscess cavity tracking toward the anterior leaf of the mitral valve. There was a small area of burrowing abscess below the left coronary leaflet, which was débrided. The right coronary leaflet was exceedingly thin-walled and resected. Several weeks after the operation the patient reports no specific complaints, with near-full level of activity.
Teaching Point Endocartitis that fails to improve within 72 hours on antibiotics should raise clinical suspicion of aortic root abscess. Antibiotic coverage for 24 hours, in general, prior to operation is necessary. Surgery is the definitive treatment. Studies indicate that a more aggressive approach of radical resection of abscess and inflamed tissue with proper reconstruction with bovine pericardium, as done in our patient, yields an excellent chance or ridding the infection. This case, a rare presentation resulting in serious complications, serves as a reminder to consider a wider range of differentials even in the absence of expected risk factors.
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