CONGRESS ABSTRACT

A 74-years-old woman presented to the ED referring weight loss and lack of appetite in the last weeks together with a two-days-history of tachycardia unresponsive to supportive therapy at home. No fever was reported. She also complained of worsening left leg pain since a couple of days, which turned into unbearable that morning. Past medical history included a mammalian cancer in complete remission. No CV risk factors were reported. Physical examination and laboratory exams were normal. While in the ED, she underwent a vascular surgery visit and an arteriovenous echography showed a clear reduction of the arterial flux associated with pain and limb hypothermia. A diagnosis of acute limb ischaemia due to common femoral artery occlusion was made and an urgent percutaneous revascularization was performed with a good final result. Due to the tachycardia, a suspicion of silent atrial fibrillation led to a cardiological evaluation. The EKG showed a synus rhythm and precordial T-waves inversion; the echocardiogram showed an apical hypokinesia and a mass in the left atrium, consistent with a mitral endocarditis. A TOE clearly revealed a thick, highly mobile 20mm pedunculated mitral mass on the posterior mitral leaflet which was associated to a severe valvular regurgitation. Due to the absence of signs of sepsis, a possible diagnosis of atrial myxoma was made. A total body CT-scan exclude further sites of thromboembolism and a coronary angiography detected a three-vessels coronary disease with no culprit artery. The patient consequently underwent a mitral valve replacement the day after: a large vegetation was removed, the following cultures turned out positive for Staphylococcus lugdunensis (MSSA) and histology was consistent with infective endocarditis. A cefazoline-based antibiotic regimen was introduced. At the two-month follow-up no valvular vegetations were found with a TEE. Endocarditis bears a wide spectrum of systemic complications. Some of them, as in the presented case, may not immediately suggest the underlying disease. Surprisingly, our patients showed one of the rarest but still highly symptomatic ones and, in a singular way, the initial clinical presentation was not indicative of an infectious disease. Multimodality imaging is of great help, but laboratory still plays a crucial role in the diagnosis of infective endocarditis. Hence a high grade of suspicion must always be kept by the physicians.