Trial Short Case 2 April 2023

Case Summary

A 66-year-old female presents to the emergency department with acute dyspnoea.

She has previously had a bioprosthetic mitral valve replacement in 2016 for Group G Strep native valve infective endocarditis, and then a redo bioprosthetic mitral valve replacement in 2017 for Strep mitis/oralis prosthetic valve endocarditis.

She was also recently admitted to hospital 1 month earlier with Group B Strep (Strep agalactiae) bacteraemia, thought to be from possible left arm cellulitis on a background of lymphoedema following a left mastectomy & axillary lymph node clearance in 2007. She received 1 week of IV ceftriaxone followed by 1 week of PO cefalexin for this and was discharged home.

On presentation this admission she was in respiratory distress. A CXR demonstrated pulmonary oedema. Bloods test demonstrated raised inflammatory markers including WCC of 21.9 and CRP of 72. Bloods cultures were taken, and she was commenced on broad spectrum antibiotics. She was diuresed with frusemide and improved clinically.

A transoesophageal echocardiogram was performed the next day by the cardiology team.

The patient has a CT brain that demonstrates ‘a predominantly peripherally enhancing centrally hypodense mass within the right inferior cerebellum with central septations. It measures 26x17mm axially and 15mm craniocaudally. No other lesions identified. No acute intracranial haemorrhage’. Clinically, the patient has mild dysdiadochokinesia but minimal other neurological symptoms.

A CT abdo/pelvis shows ‘a poorly defined area of non-enhancement within the superior spleen, likely to represent area of septic emboli’.

Questions:

  1. Describe the echo findings

  2. What are the indications for surgery in acute prosthetic endocarditis

  3. How would you manage the timing of surgery

  4. Describe your surgical management