A diabetic 26-year-old man was admitted to our center for prolonged fever for 2 weeks associated with fatigue and general malaise, as well as loss of appetite. He had no history of rheumatic or congenital heart disease. At admission, the patient was febrile at 39 C and tachycardic. His lung sounds were clear, and no cardiac murmur was audible. There were no signs of heart failure.
The laboratory tests showed an inflammatory syndrome. An echocardiographic evaluation revealed a normal global systolic left ventricular function, no valvular disease but we noted a 15 mm x 11 mm mobile oscillating large mass with an echogenic content attached to the mitral anterolateral papillary muscle [Figure 1]. The diagnoses of a large septic vegetation or a papillary hydatid cyst were hypothesized.
Hence, after infectious investigations (hemocultures, hydatid serology, and mycobacterium tuberculosis research), empirical intravenous (IV) antibiotic therapy was initiated with ceftriaxone, teicoplanin, metronidazole, and rifampicin. However, there was no clinical amelioration and fever had persisted. A thoracoabdominal computed tomography revealed multiple hypodensities of the brain, the liver, and the spleen consistent with septic emboli. Few days after hospitalization, the patient's clinical condition worsened and pulmonary congestion appeared suddenly. The physical examination revealed a new pansystolic murmur consistent with mitral regurgitation. There was no electrocardiographic change suggesting an acute or subacute myocardial infarction.
Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) examinations were repeated. Echocardiographic studies showed a hyperdynamic left ventricle with no regional wall motion abnormality but we noticed severe mitral regurgitation with a prolapse of the anterior mitral valve due to the rupture of the mitral anterolateral papillary muscle, which explained the patient clinical status [Figure 2]. The diagnosis of IE complicated by severe mitral regurgitation was established. The patient underwent urgent prosthetic mitral valve replacement. On surgical inspection, complete rupture of the anterolateral papillary mitral muscle was found [Figure 3].
Pathology showed a nonspecific inflammation, ischemic necrosis, and focal abscesses which were consistent with IE. Given the histologic examination results, the diagnosis was a rupture of anterolateral papillary muscle secondary to mitral valve IE. After 6 weeks of IV antibiotic therapy, the patient was uneventfully discharged.