Myocardial abscess (MA) is a suppurative infection of the myocardium, endocardium, native or prosthetic valves, perivalvular structures or the cardiac conduction system. It is a potentially life-threatening disease, where early recognition and institution of appropriate medical and surgical therapy is vital for patient survival. The overall mortality rate associated with Staphylococcus aureus endocarditis is 42%. If treated with appropriate antibiotics and surgery, the mortality rate falls to 25%. The presence of an intracardiac abscess results in a 13.7-fold increase in mortality. In the past, most cases of MA were found during autopsy; however, detection of MA can now be achieved antemortem, using noninvasive diagnostic modalities including transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), radionuclide scintigraphy, computed tomography (CT) scan and cardiac magnetic resonance imaging (CMRI).
A 28-year-old intravenous drug user was admitted in a district general hospital with a 2-week history of fever, malaise and myalgia. He had no past medical history of note. On examination he was pyrexial but haemodynamically stable. His cardiovascular examination revealed signs of tricuspid regurgitation. His respiratory, abdominal and neurological examination was normal. Clinically, the diagnosis of infective endocarditis (IE) was suspected. Three sets of blood cultures were drawn and empirical intravenous antibiotic treatment commenced.
His blood tests showed leukocytosis with predominant neutrophilia and mild normochormic, normocytic anaemia. His electrocardiogram revealed non-specific ST-changes but no conduction abnormality. His chest X-ray was unremarkable. TTE confirmed vegetations on the tricuspid valve with severe regurgitation. All other valves were normal. Blood cultures grew S. aureus and vigorous antibiotic treatment was continued appropriately. However, the patient's condition continued to deteriorate with spiking fever and raised inflammatory markers. He was referred to the regional cardiothoracic centre for evaluation of valve surgery in view of uncontrolled infection.
On arrival at the cardiothoracic centre, the patient was acutely unwell with a temperature of 38.5├é┬░C, pulse of 120 beats per minute, blood pressure of 100/70 and respiratory rate of 26 breaths per minute. He had signs of severe tricuspid regurgitation and right heart failure. His repeat chest X-ray showed multiple cavitating lesions depicting metastatic pulmonary abscesses. There was also evidence of splenic abscesses on his abdominal ultrasound scan. Repeat TTE confirmed vegetations on the tricuspid valve with severe regurgitation but additionally it showed a small echo-free space in the wall of the left ventricle, raising suspicion of an MA (Figure 1). TOE was planned to evaluate this further but the patient was unable to tolerate it. Urgent CMRI was obtained, which revealed a 4.5 cm diameter left ventricular posterior wall abscess contained by only a 2 mm thin layer of myocardium (Figure 2 and Additional file 1). Urgent surgical intervention was planned but, unfortunately, the patient had a cardiac arrest prior to surgery and could not be resuscitated.
|Published online 2008 August 5. doi: 10.1186/1752-1947-2-258.
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