IE Complicated by Aortic Root Abscess and Contained Rupture Presenting With Pericarditis and New Pericardial Effusion

A 39-year-old male patient without any previous medical history presented to a peripheral hospital's emergency department with an acute onset of confusion. The confusion was preceded by a flu-like prodrome followed by persistent fevers and periodic chest discomfort. Initial investigations yielded an abnormal lumbar puncture and streptococcal bacteremia. His initial electrocardiogram (ECG) showed sinus tachycardia, and his peak troponin I was 0.291 mcg/L along with a C-reactive protein of 228.1 mg/L.

The patient was promptly started on intravenous antibiotics for meningitis. Investigations for the source of bacteremia were initiated, including a transthoracic echocardiogram (TTE) that showed a left ventricular ejection fraction of 60-65% and moderately increased pulmonary pressures of 48 mmHg. Also noted was a heavily calcified and moderately stenotic aortic valve (peak-to-mean pressure gradient 53/35 mmHg, dimensionless index 0.37, aortic valve area 1.43 cm2). No vegetation was identified. The surface echocardiogram was followed by a transesophageal echocardiogram (TEE) that confirmed the former and identified mild-to-moderate aortic insufficiency but, again, could not identify a vegetation nor any obvious complication of infective endocarditis (IE).

Following several days of intravenous antibiotics, the patient's clinical status improved, including sterilization of the blood cultures. Fever and leukocytosis, however, persisted despite 10 days of antibiotic therapy. On the 11th day of hospitalization, the patient developed acute chest pain, diaphoresis, and hypotension, prompting an ECG that showed diffuse ST elevations compatible with acute pericarditis. The ensuing echocardiogram showed a new, small circumferential pericardial effusion. The patient was subsequently started on anti-inflammatory medications as well as colchicine for pericarditis. He was then transferred to our tertiary center for possible pericardiocentesis.

A repeat echocardiogram was significant for an evolving pericardial effusion, which now had septations and echo-dense regions that appeared to be complex in nature. The anterior part of the aortic root appeared thickened; however, the image quality was suboptimal (Videos 1-2). Repeat TEE was significant for a thickened aortic root, along the posterior, medial, and anterior aspects, but once again failed to identify a vegetation on the aortic valve cusps (Video 3). Moreover, more echo-dense material was noted within the pericardial space, along the right atrium and right ventricle, than was appreciated on the surface echocardiogram (Video 4).

Video 1

Video 2

Video 3

Video 4

Considering that the initial TEE was not confirmatory for IE nor for aortic root abscess, what would have been the best approach to rule out an infection of the aortic root/annulus?

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