A Case Study: Left Atrial Mural Vegetations in a Patient with Infective Endocarditis Complicated by Septic Embolism

Abstract

Infective Endocarditis (IE) is associated with severe complications including cardiac failure, septic embolisation to distant organs, and significant mortality, if not promptly diagnosed and treated. It is therefore pertinent to perform diagnostic echocardiography in patients who have clinical suspicion of IE as it can reveal size and location of vegetations along with the extent of infection in the surrounding tissue and aid in confirming a therapeutic response. Vegetations in IE usually involve the valves but rarely may be located in the ventricles. Left atrial mural vegetation is a very rare condition. The common pathogen causing IE is Staphylococcus Aureus seen in more than half of the cases. Streptococcus Viridans is a less virulent organism, found as a part of normal oral, respiratory, gastrointestinal and genital bacterial flora but has the potential to cause invasive bacteremia and infections. A 20-year-old female presented with fever, palpitations, and shortness of breath on exertion for last 4 months. She then had developed sudden onset left sided body weakness and facial weakness. She had an ill-sustained heaving apex beat with grade 4 pan-systolic murmur at mitral area. There was upper motor left-sided uncrossed hemiplegia. Transesophageal echocardiography revealed anterior mitral leaflet vegetation along with 2 vegetations attached to the posterior left atrial wall and the jet of mitral valve regurgitation was directed to the posterior wall of the left atrium towards the vegetations. Blood cultures revealed gram-positive Streptococcus Viridians sensitive to vancomycin which was continued. MRI Brain revealed hypodense T1WS and hyperdense T2WS/FLAIR area in the right lentiform nucleus. The final diagnosis was Infective Endocarditis with left atrial mural vegetations due to Streptococcus Viridians, complicated by septic embolisation causing stroke. At 6-week follow up, she was clinically asymptomatic and a repeat echocardiography demonstrated resolution of the vegetations.