Images and Case Report by Dr. Pooja Sheth
Case:
53 year old male with a past medical history of mitral regurgitation, CKD3, Celiac’s Disease, endocarditis (previously treated at outside hospital, but left against medical advice prior to completion of treatment), presented with shortness of breath and increasing leg and scrotum swelling for one month. Pt was seen by CT surgery during a recent admission in May 2019 and had discussed valve replacement, but the patient refused at that time. Vitals were: BP 119/87, P 92, T 97.5F, RR 18, SpO2 100%. Patient arrived short of breath and was found to have decreased breath sounds in the right and left lower lung fields. Patient also had lower extremity and scrotal edema. Labs were significant for pro- BNP of 3837.
Image 1: Parasternal Long view of heart
Image 2: Apical Four Chamber view of the heart with mobile hyperechoic mass on mitral valve leaflet
Image 3: Parasternal Short View of the heart; mitral valve vegetation visible
Subsequent Formal TTE found:
Mitral Valve: The mitral valve leaflets are moderately thickened. An irregularly shaped multilobar mobile mass (2.2 cm) is noted on the atrial surface of the P2-3 segments of the mitral valve. There are focal calcifications in the mass suggestive of its chronicity. Severe mitral valve regurgitation.
Teaching points:
- Infective endocarditis is difficult to diagnose in the ED. Murmurs can be difficult to auscultate in a loud ER, symptoms can be non-specific, skin manifestations can be rare or overlooked.
- When attempting to diagnose endocarditis, one can use a bedside TTE on a patient with clinical suspicion. Look for a mobile mass on valve leaflets usually on the upstream side of valve. The best view depends on the valve of interest.
- POCUS to look for endocarditis can expedite management of septic patients with relatively large vegetations discovered on point-of-care cardiac ultrasound.
- One study suggests approximately 25% of vegetations less than 5mm, and 70% vegetations 6- 10mm in size can be visualized (1). Another study found that transthoracic echocardiography is 84% sensitive for vegetations greater than 10mm in size (2).
- Hyperechoic masses seen on POCUS have a differential including vegetation, myxomatous process, tumors, thrombi, or imaging artifact.
[1] Erbel R, Rohmann S, Drexler M, et al. Improved diagnostic value of echocardiography in patients with infective endocarditis by transesophageal approach. A prospective study. Eur Heart J. 1988 Jan;9(1):43–53.
[2] Reynolds HR, Jagen MA, Tunick PA, et al. Sensitivity of transthoracic versus
transesophageal echocardiography for the detection of native valve vegetations in the modern
era. J Am Soc Echocardiogr. 2003 Jan;16(1):67–70.