https://doi.org/10.1007/s00392-025-02625-4
1Herzzentrum Leipzig - Universität Leipzig Universitätsklinik für Herzchirurgie Leipzig, Deutschland; 2Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland
History of presentation
A 51-year-old man was initially referred to an oncological ward due to anemia and suspicion of lymphoma. The patient complained about weight loss of 10 kilograms over a period of one year, chronic joint pain and diarrhea. Shortly after admission, the patient required cardiopulmonary resuscitation due to asystole.
Investigations and managment
After successful resuscitation, transesophageal echocardiography was performed revealing large, mobile vegetations on the aortic (Panel A, arrow, LA = left atrium, LV = left ventricle) and mitral valves (Panel B, arrow) suggestive of endocarditis. Empiric intravenous antibiotic therapy was administered immediately. Due to progression of the septic shock, the patient underwent emergency surgery. After aortic and mitral valve replacement with two mechanical prosthetic heart valves, high dose catecholamine therapy and continuous dialysis was required. Icterus, ascites and laboratory elevation of liver parameters lead to conduction of a whole body computed tomography, where no infectious focus could be detected. Examination of the aortic and mitral valve tissue revealed Tropheryma whipplei as the cause of infective endocarditis. Subsequent duodenal biopsy confirmed the results, demonstrating period acid Schiff (PAS)-positive macrophages in the mucosa (Panel C, hematoxylin eosin staining and D, PAS-staining). Echocardiography at discharge detected severe paravalvular leakage of the mitral valve prosthesis and new diagnosis of tricuspid regurgitation. Also, endocarditic vegetations on both prosthetic valves could not be ruled out. The patient underwent reoperation two weeks after the initial cardiac surgery with implantation of two biological valves in aortic and mitral position and tricuspid valve repair.
Follow up
Surgery was performed without any complications and the patient was discharged to cardiac rehabilitation successfully. The patient received antibiotic therapy with ceftriaxone for 6 weeks and cotrimoxazole for 12 months, in accordance with recent guidelines.