Case Presentation:
A 65-year-old female was brought to an outside hospital with complaints
of word-finding difficulties and altered mental status for two days. Her
past medical history was notable for hypertension, dyslipidemia,
multiple previous cerebrovascular accidents without any residual
deficits, peripheral vascular disease, atrial fibrillation on Apixaban,
coronary artery bypass grafting (CABG) with bio-prosthetic mitral valve
(BPMV) replacement and left atrial appendage ligation six years ago. She
was afebrile on presentation and had no other neurological deficits on
her exam. Blood work indicated mild leukocytosis of 11.4
x103 uL (reference 4.5–11), urine analysis, and
culture was negative for infection. Computed tomography (CT) of the head
showed multiple small old infarcts. Head and neck computed tomography
angiography (CTA) revealed no evidence of large vessel occlusion or
critical stenosis. Echocardiography showed an ejection fraction of 70%
and a large echo density on the posterior part of the BPMV on the
ventricular side. She was transferred to our facility for further
evaluation of the mass. TEE showed a #25 Carpentier Edwards’s BPMV with
a large echogenic mass measuring 2.6 cm x 1.7 cm attached to the
ventricular side of the mitral annulus (Figures 1 and 2). From the
echotexture, location, and size, it appeared to be more likely a
neoplasm than vegetation. The mean gradient across the valve was 7 mm
Hg, and the valve area by three-dimensional planimetry was 2
cm2. Post-TEE patient had worsening leukocytosis to
21x103 ul, which prompted consult with an infectious
disease specialist who recommended blood cultures. Growth ofStreptococcus Gordonii was noted in 4/4 culture bottles. She was
started on intravenous (IV) ceftriaxone 2g per 24 h with gentamicin
3mg/kg every 48 h for synergy. Repeat blood cultures were negative.
Subsequent brain magnetic resonance imaging (MRI) showed multiple small
acute infarcts in the left posterior parietal lobe. The patient
underwent excision of Mitral annular mass along with redo mitral valve
replacement and CABG x 1 after completion of two weeks of antibiotics.
The patient had an uneventful postoperative recovery. While the surgeon
described the mass as suspicious for myxoma, subsequent pathology was
notable for fragments of material consisting of fibrin, thrombus, and
acute inflammation, consistent with vegetation. No vegetation was
identified on the cusps of the BPMV specimen.