Unusual Presentation of Infective Endocarditis as Anterolateral STEMI
A 72–year-old woman with past medical history significant for hypertension and diabetes presented with anterolateral ST-segment myocardial infarction (STEMI). Coronary angiogram showed the presence of thrombus in the proximal left anterior descending (LAD) artery (Figure 1). Successful aspiration thrombectomy followed by stenting of the proximal LAD was performed. There was no evidence of underlying atheromatous plaque or stenosis, raising the suspicion for an embolic phenomenon. At presentation, though patient was afebrile, she was noted to have persistently elevated white blood cell count. Transesophageal echocardiogram showed a large mobile mass attached to the atrial side of the mitral valve leaflet (Video 1). Only mild mitral regurgitation was noted. Differential diagnosis of the mass included vegetation vs. atrial myxoma. Blood cultures were positive for coagulase negative staphylococcal bacteria. During the hospital course, the patient developed acute abdominal pain. Computed tomography (CT) imaging of the abdomen revealed multiple splenic infarcts. Given the persistent bacteremia and evidence of embolization, she was taken for surgical removal of the mass. Intra operative findings included a large friable mass over the mitral valve. The posterior leaflets (P1/P2 segments) were perforated. An attempted repair of the perforated posterior leaflet failed and she underwent mitral valve replacement. Histology of the mass revealed fibrinous debris with acute inflammation, pus formation and bacterial overgrowth consistent with acute infective endocarditis. She had a long post-operative course complicated by respiratory failure, inability to wean off from the ventilator in the setting of hospital acquired pneumonia and acute kidney injury. She subsequently required tracheostomy and was eventually discharged to a long term acute care facility. This case demonstrates that septic embolization from a large vegetation resulting in acute coronary syndrome can be the initial presentation of infective endocarditis.
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