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Rheumatoid arthritis mimicking infective endocarditis with severe aortic regurgitation and aortic root abscess: a case report.

ABSTRACT:

Background

Rheumatoid arthritis (RA) may involve the cardiovascular system and can cause significant structural cardiac disease. RA mimicking infective endocarditis (IE) is rarely reported.

Case summary

A 46-year-old man with a medical history of seropositive RA attended a planned outpatient visit for infliximab treatment. The pre-infusion examination revealed a pulse of 41 b.p.m. and the following electrocardiogram showed 3rd degree atrioventricular block. A temporary pacemaker was inserted, and subsequent transthoracic and transoesophageal echocardiograms showed severe aortic valve regurgitation with thickened cusps and thus raised suspicion of infective aortic endocarditis with root abscess. The patient underwent surgery with valve and root replacement the next day. What was thought to be IE, proved to be suppurative and granulomatous inflammation with sporadic necrosis and hyaline fibrosis, compatible with a rheumatoid nodule linked to the patient's RA diagnosis.

Discussion

IE is a disease with high mortality and morbidity. In some cases of IE perivalvular cavities develop, most commonly abscesses and/or pseudoaneurysms, which necessitates surgery. Several conditions may mimic IE: for example, malignant and benign tumours, rheumatic diseases, and common age-related valve calcification. In patients with valvular vegetations that are 'culture-negative', alternative pathologies should be considered.

SUBMITTER: Kyhl F

PROVIDER: S-EPMC7898585 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.

Project description:BACKGROUND:Aortic root abscess (ARA) is a major complication of infective endocarditis that is associated with increased morbidity and mortality. Limited data are present about patient characteristics and outcomes in this lethal disease. We aimed to study the clinical and echocardiographic characteristics of patients with ARA compared to patients with left-sided infective endocarditis without ARA. We included patients with a definite diagnosis of left-sided infective endocarditis according to modified Duke's criteria. The patients were classified into two groups according to the presence of ARA (ARA and NO-ARA groups). All the patients were studied regarding their demographic data, clinical characteristics, laboratory and imaging data, and complications. RESULTS:We included 285 patients with left-sided infective endocarditis. The incidence of ARA was 21.4% (61 patients). Underlying heart disease, mechanical prosthesis, bicuspid aortic valve, and prior IE were significantly higher in ARA. The level of CRP was higher in ARA (p = 0.03). ARA group showed more aortic valve vegetations (73.8% vs. 37.1%, p < 0.001), more aortic paravalvular leakage (26.7% vs. 4.5%, p < 0.001), and less mitral valve vegetations (21.3% vs. 68.8%, p < 0.001). Logistic regression analysis showed that the odds of ARA increased in the following conditions: aortic paravalvular leak (OR 3.9, 95% CI 1.2-13, p = 0.03), mechanical prosthesis (OR 3.6, 95% CI 1.5-8.7, p = 0.005), aortic valve vegetations (OR 3.0, 95% CI 1.2-8.0, p = 0.02), and undetected organism (OR 2.3, 95% CI 1.1-4.6, p = 0.02), while the odds of ARA decreased with mitral valve vegetations (OR 0.2, 95% CI 0.08-0.5, p = 0.001). We did not find a difference between both groups regarding the incidence of major complications, including in-hospital mortality. CONCLUSION:In our study, ARA occurred in one fifth of patients with left-sided IE. Patients with mechanical prosthesis, aortic paravalvular leakage, aortic vegetations, and undetected organisms had higher odds of ARA, while patients with mitral vegetations had lower odds of ARA.