Contributed by Robert Bubar, MD and Bryan Stevens, MD
The patient is a gentleman in his 40s with a history of cerebrovascular accident and questionable medication compliance who presented with right-sided weakness and aphasia. Imaging revealed a stroke involving the left middle cerebral artery (MCA) territory for which tissue plasminogen activator (tPA) was administered. Shortly after receiving tPA his weakness worsened and follow-up imaging demonstrated intraparenchymal hemorrhages. A brain MRI performed as part of the stroke workup showed multiple foci of embolic infarcts. A transesophageal echocardiogram revealed aortic insufficiency with calcifications, nodular deposits, and vegetations present on the aortic valve. Blood cultures were obtained and the patient was started on cefepime and vancomycin for presumed endocarditis. Cardiology was consulted and recommended aortic valve replacement to be performed 4-6 weeks following the initial stroke. Blood cultures demonstrated no growth and the patient was maintained on empiric antibiotic treatment until the time of his heart surgery.
One month after his initial presentation, the patient was taken to the operating room for aortic valve replacement. Transesophageal echocardiogram performed just prior to the patient's planned surgery continued to show a large aortic valve vegetation, moderate-to-severe aortic regurgitation, and severely dilated left ventricle. On intraoperative gross examination the native aortic valve leaflets appeared severely destroyed with granular deposits that were inconsistent with the usual vegetations seen with bacterial endocarditis. The native aortic valve leaflets were sent for tissue culture. Aerobic and anaerobic tissue cultures demonstrated no growth at time of report finalization. Preliminary fungal cultures demonstrated no growth at 7 days. A tissue sample was sent for 16S rRNA gene sequencing which was ultimately able to provide identification of an organism. In light of the new diagnosis, the patient's therapy was switched to doxycycline and hydroxychloroquine.