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Echocardiographic features of an unruptured mycotic aneurysm of the right aortic sinus of valsalva
Echocardiographic Features of an Unruptured Mycotic Aneurysm of the Right Aortic Sinus of Valsalva Columbus Batiste, MD, Ramesh C. Bansal, MD, FASE, and Anees J. Razzouk, MD, Loma Linda, California
This report describes a 25-year-old man with a pierced tongue in whom Streptococcus constellatus endocarditis of the aortic valve developed. Bacterial endocarditis in this patient was complicated by the development of a mycotic aneurysm of the right
The art of body piercing has been described for
thousands of years. The rise in popularity of body piercing in head and neck regions has resulted in an increase in published reports of complications related to this practice.1,2 Although no study has examined the correlation between body piercing and infective endocarditis (IE), there have been an increasing number of case reports documenting the occurrence of IE in patients with tongue piercing.1,2 There have only been rare reports of transthoracic echocardiographic findings in patients with unruptured mycotic aneurysms of aortic sinus of Valsalva.3,4 This report describes the transthoracic and transesophageal echocardiographic (TEE) findings of an unruptured mycotic aneurysm of the right aortic (RA) sinus of Valsalva. The only apparent risk factor for development of aortic valve endocarditis was the patient’s pierced tongue.
CASE REPORT A 25-year-old man originally presented with a history of headache and blurred vision. He denied a history of heart murmur or fever. He denied history of intravenous drug abuse. His history was unremarkable for medical or surgical illnesses. He, however, had his tongue pierced with a metal stud 2 years previously. He was initially admitted to a local hospital with persistent headaches, neck pains, and visual problems. Physical examination showed pulse of 84 From the Division of Cardiology and Cardiothoracic Surgery, Loma Linda University School of Medicine. Reprint requests: Ramesh C. Bansal, MD, FASE, Adult Echocardiography Laboratory, Loma Linda University Medical Center, 11234 Anderson St, Room 4420, Loma Linda, CA 92354. 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.01.002
474
aortic sinus of Valsalva. Transthoracic and transesophageal echocardiographic studies were useful for the diagnosis of this rare lesion. Findings were confirmed at operation. (J Am Soc Echocardiogr 2004;17:474-7.)
bpm, blood pressure of 160/100 mm Hg, and temperature of 99°F. The oral cavity was pink, and a metal stud was in place in the middle portion of his tongue. There was a grade 1/6 ejection systolic murmur in the aortic area. Examination of the visual fields revealed right homonymous inferior quadrantic hemianopia. The remainder of the physical examination was unremarkable. Laboratory studies showed hemoglobin of 13.9 g/dL and white blood cell count of 4.4 ⫻109/L with a normal differential. The blood urea nitrogen was 15 mg/dL and creatinine was 1.0 mg/dL. Two blood cultures drawn initially revealed gram-positive cocci, which were later identified as Streptococcus constellatus. Magnetic resonance imagining scan showed a 2 cm–sized lesion consistent with infarction involving the left medial occipital lobe. Magnetic resonance angiography showed normal examination of the circle of Willis. His electrocardiogram showed normal in sinus rhythm and no abnormalities. Transthoracic parasternal long- and short-axis imaging (Figures 1 and 2) showed thickening of the aortic valve with good opening and mild central aortic regurgitation (Figure 2). In addition, an echolucent space was seen both in systole and diastole anterior to the right aortic sinus of Valsalva. TEE clearly demonstrated a small vegetation on the left margin of the left cusp (Figure 3). TEE also clearly showed a mycotic aneurysm of the right aortic sinus with a narrow (2-mm) communication at the base of the right cusp. Diastolic TEE frame showed mosaic-colored diastolic jet coming out of the mycotic aneurysm. The organisms identified on blood cultures were very sensitive to penicillin. Intravenous penicillin was, therefore, started at a dose of 5 million units every 4 hours. Repeat echocardiography and TEE after 2 weeks showed slight enlargement in the size of the aortic mycotic aneurysm. He was taken to operation for planned aortic valve replacement and repair of the mycotic aneurysm. The direct surgical inspection revealed a trileaflet aortic valve with 8-mm vegetation on the margin of the left aortic cusp (Figure 3). There was evidence of a 2- ⫻
Journal of the American Society of Echocardiography Volume 17 Number 5
Batiste, Bansal, Razzouk 475
Figure 1 Parasternal long-axis views in diastole and systole without and with color flow imaging show thickening of aortic valve (AV) cusps and right sinus of Valsalva aneurysm (arrow). Color flow imaging showed diastolic mosaic-colored flow out aneurysm (arrow). LA, Left atrium; LV, left ventricle.
1-cm mycotic aneurysm of the right aortic sinus. This aneurysm communicated with the aortic lumen through a narrow mouth in the region of right sinus adjacent to the anterior commissure. The mouth of the mycotic aneurysm was patched with autologus pericardium and aortic valve was replaced with a No. 25 mechanical prosthesis (Sulzer Carbomedics, Austin, Tex). He was discharged home within a week after his operation. He completed a 6-week course of antibiotics at home and remains asymptomatic 1 year after his operation.
DISCUSSION IE and Body Piercing S constellatus is 1 of the 3 organisms in the S intermedius group, the other 2 being S anginosus and S intermedius. This group was previously called S milleri group.5 This organism has commonly been found in the flora of the mouth, and long been recognized as a pathogen in IE. It has a high propensity for suppuration and abscess formation.5 Our patient had his tongue pierced for 2 years before the development of IE of his aortic valve. There were no other apparent risk factors for IE. IE has been reported 1 week to 3 years after body piercing.2 Colonization around the tongue stud from constant trauma likely caused bacteremia and resulted in endocarditis of a previously normal appearing trileaflet aortic valve.
Mycotic Aneurysm of Aortic Sinus of Valsalva Aortic valve endocarditis may be complicated by ring abscess,6,7 and subaortic complications involving the mitral-aortic intervalvular fibrosa and mitral valve apparatus.8,9 Mycotic aneurysms involving the aortic sinus of Valsalva have infrequently been described.3,4,10-14 Most of the echocardiographic reports have been in subjects with ruptured right sinus of Valsalva and communication with the right atrium11,12 or right ventricle.13 Rothbart and Chahine14 reported a case of left sinus of Valsalva aneurysm that had ruptured into the left ventricle. Our case had the unusual and rare complication of mycotic aneurysm of the right aortic sinus of Valsalva. TEE clearly showed the location of the aneurysm and its communication with the main aortic lumen by a narrow orifice located at the base of the right aortic cusp. The aneurysmal cavity was patent in systole and diastole (Figures 1 and 2). There was flow out of the aneurysm into the aortic lumen in diastole (Figure 3). The systolic flow into the aneurysm was, however, not well seen. TEE permitted evaluation of anatomy and flow characteristics of this unruptured mycotic aneurysm. Takach et al3 published a surgical series of aortic sinus of Valsalva aneurysms of 129 patients. These aneurysms were related to IE in 33% of cases and occurred in association with other congenital abnormalities in the remaining (Marfan syndrome, bicuspid aortic valve, and ventricular septal defects).3 Cineangiog-
476 Batiste, Bansal, Razzouk
Journal of the American Society of Echocardiography May 2004
Figure 2 Parasternal short-axis imaging in diastole without and with color flow imaging showing trileaflet aortic valve (AV), mild central aortic regurgitation (AR) (arrowhead), and right sinus of Valsalva aneurysm (arrow). There is diastolic color flow jet related to sinus of Valsalva aneurysm. RVOT, Right ventricular outflow tract.
Figure 3 Multiple transesophageal echocardiographic images of aortic root. Upper left panel shows systolic opening of trileaflet aortic valve. Small vegetation (V) is noted at margin of left cusp (arrowhead). Sinus of Valsalva aneurysm communicated through small mouth of 2 mm (arrow) at base of right cusp to aortic lumen. Diastolic frame with color flow imaging shows diastolic jet (arrow) out of aneurysm. Bottom panel shows surgical specimen of excised left aortic (LA) cusp (L) with V. N, Noncoronary cusp; PA, pulmonary artery; R, right aortic cusp; RA, right atrium; RV, right ventricle.
raphy was used to diagnose these lesions in this report. These investigators described variable natural history of these lesions, and no guidelines were provided regarding the timing of surgical intervention. It may be prudent to perform operation on mycotic aortic sinus of Valsalva aneurysm related to endocarditis because of potential for unexpected rupture. TEE allowed evaluation of anatomy and flow characteristics of this unruptured mycotic an-
eurysm, and permitted successful surgical repair of this rare lesion.
REFERENCES 1. Harding PR, Yerkey MW, Deye G, Storey D. MARSA endocarditis secondary to tongue piercing. J Miss State Med Assoc 2002;43:109.
Journal of the American Society of Echocardiography Volume 17 Number 5
2. Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis 2002;8:850-1. 3. Takach JJ, Reul GJ, Duncan M, Cooley DA, Livesay JJ, Ott DA, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg 1999;68:1573-7. 4. Shulman R, Khuri S, Ray BJ, Paris AF. Echocardiographic features of an unruptured aneurysm of the right sinus of Valsalva. Chest 1980;77:700-2. 5. Whiley RA, Fraser HY, Hardie JM. Phenotypic differentiation of Streptococcus constellantus, Streptococcus intermedius, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infection. J Clin Microbiol 1990;28:1497-501. 6. Daniel WG, Mugge A, Martin RP, Lindert O, Hausmann D, Nonnast-Daniel B, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991;324:795-800. 7. Graupner C, Vilacosta I, San Roman JA, Ronderos R, Sarria C, Fernandez C, et al. Periannular extension of infective endocarditis. J Am Coll Cardiol 2002;39:1204-11. 8. Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis: clinical and surgical implications. Circulation 1992;86:35362.
Batiste, Bansal, Razzouk 477
9. Bansal R. Infective endocarditis. Med Clin North Am 1995; 79:1205-35. 10. Shaffer EM, Snider AR, Beekman RH, Behrendt DM, Peschiera AW. Sinus of Valsalva aneurysm complicating bacterial endocarditis in an infant; diagnosis with two-dimensional and Doppler echocardiography. J Am Coll Cardiol 1987;9:58891. 11. Chow LC, Dittrich HC, Dembitsky WP, Nicod PH. Accurate localization of ruptured sinus of Valsalva aneurysm by real time two-dimensional Doppler flow imaging. Chest 1988;94: 462-5. 12. Cooper MJ, Silverman NH, Huey E. Group A beta-hemolytic streptococcal endocarditis precipitating rupture of sinus of Valsalva aneurysm: evaluation by two-dimensional, Doppler, and contrast echocardiography. Am Heart J 1988;115: 1132-4. 13. Bansal RC, Wangsnes KM, Bailey L. Right aortic sinus of Valsalva-to-right ventricle fistula complicating bacterial endocarditis of membranous ventricular septal defect: evaluation by two-dimensional, color flow, and Doppler echocardiography. J Am Soc Echocardiogr 1993;6:308-11. 14. Rothbart RM, Chahine RA. Left sinus of Valsalva aneurysm with rupture into the left ventricular outflow tract: diagnosis by color-encoded Doppler imaging. Am Heart J 1990;120: 224-7.
This report describes a 25-year-old man with a pierced tongue in whom Streptococcus constellatus endocarditis of the aortic valve developed. Bacterial endocarditis in this patient was complicated by the development of a mycotic aneurysm of the right
The art of body piercing has been described for
thousands of years. The rise in popularity of body piercing in head and neck regions has resulted in an increase in published reports of complications related to this practice.1,2 Although no study has examined the correlation between body piercing and infective endocarditis (IE), there have been an increasing number of case reports documenting the occurrence of IE in patients with tongue piercing.1,2 There have only been rare reports of transthoracic echocardiographic findings in patients with unruptured mycotic aneurysms of aortic sinus of Valsalva.3,4 This report describes the transthoracic and transesophageal echocardiographic (TEE) findings of an unruptured mycotic aneurysm of the right aortic (RA) sinus of Valsalva. The only apparent risk factor for development of aortic valve endocarditis was the patient’s pierced tongue.
CASE REPORT A 25-year-old man originally presented with a history of headache and blurred vision. He denied a history of heart murmur or fever. He denied history of intravenous drug abuse. His history was unremarkable for medical or surgical illnesses. He, however, had his tongue pierced with a metal stud 2 years previously. He was initially admitted to a local hospital with persistent headaches, neck pains, and visual problems. Physical examination showed pulse of 84 From the Division of Cardiology and Cardiothoracic Surgery, Loma Linda University School of Medicine. Reprint requests: Ramesh C. Bansal, MD, FASE, Adult Echocardiography Laboratory, Loma Linda University Medical Center, 11234 Anderson St, Room 4420, Loma Linda, CA 92354. 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.01.002
474
aortic sinus of Valsalva. Transthoracic and transesophageal echocardiographic studies were useful for the diagnosis of this rare lesion. Findings were confirmed at operation. (J Am Soc Echocardiogr 2004;17:474-7.)
bpm, blood pressure of 160/100 mm Hg, and temperature of 99°F. The oral cavity was pink, and a metal stud was in place in the middle portion of his tongue. There was a grade 1/6 ejection systolic murmur in the aortic area. Examination of the visual fields revealed right homonymous inferior quadrantic hemianopia. The remainder of the physical examination was unremarkable. Laboratory studies showed hemoglobin of 13.9 g/dL and white blood cell count of 4.4 ⫻109/L with a normal differential. The blood urea nitrogen was 15 mg/dL and creatinine was 1.0 mg/dL. Two blood cultures drawn initially revealed gram-positive cocci, which were later identified as Streptococcus constellatus. Magnetic resonance imagining scan showed a 2 cm–sized lesion consistent with infarction involving the left medial occipital lobe. Magnetic resonance angiography showed normal examination of the circle of Willis. His electrocardiogram showed normal in sinus rhythm and no abnormalities. Transthoracic parasternal long- and short-axis imaging (Figures 1 and 2) showed thickening of the aortic valve with good opening and mild central aortic regurgitation (Figure 2). In addition, an echolucent space was seen both in systole and diastole anterior to the right aortic sinus of Valsalva. TEE clearly demonstrated a small vegetation on the left margin of the left cusp (Figure 3). TEE also clearly showed a mycotic aneurysm of the right aortic sinus with a narrow (2-mm) communication at the base of the right cusp. Diastolic TEE frame showed mosaic-colored diastolic jet coming out of the mycotic aneurysm. The organisms identified on blood cultures were very sensitive to penicillin. Intravenous penicillin was, therefore, started at a dose of 5 million units every 4 hours. Repeat echocardiography and TEE after 2 weeks showed slight enlargement in the size of the aortic mycotic aneurysm. He was taken to operation for planned aortic valve replacement and repair of the mycotic aneurysm. The direct surgical inspection revealed a trileaflet aortic valve with 8-mm vegetation on the margin of the left aortic cusp (Figure 3). There was evidence of a 2- ⫻
Journal of the American Society of Echocardiography Volume 17 Number 5
Batiste, Bansal, Razzouk 475
Figure 1 Parasternal long-axis views in diastole and systole without and with color flow imaging show thickening of aortic valve (AV) cusps and right sinus of Valsalva aneurysm (arrow). Color flow imaging showed diastolic mosaic-colored flow out aneurysm (arrow). LA, Left atrium; LV, left ventricle.
1-cm mycotic aneurysm of the right aortic sinus. This aneurysm communicated with the aortic lumen through a narrow mouth in the region of right sinus adjacent to the anterior commissure. The mouth of the mycotic aneurysm was patched with autologus pericardium and aortic valve was replaced with a No. 25 mechanical prosthesis (Sulzer Carbomedics, Austin, Tex). He was discharged home within a week after his operation. He completed a 6-week course of antibiotics at home and remains asymptomatic 1 year after his operation.
DISCUSSION IE and Body Piercing S constellatus is 1 of the 3 organisms in the S intermedius group, the other 2 being S anginosus and S intermedius. This group was previously called S milleri group.5 This organism has commonly been found in the flora of the mouth, and long been recognized as a pathogen in IE. It has a high propensity for suppuration and abscess formation.5 Our patient had his tongue pierced for 2 years before the development of IE of his aortic valve. There were no other apparent risk factors for IE. IE has been reported 1 week to 3 years after body piercing.2 Colonization around the tongue stud from constant trauma likely caused bacteremia and resulted in endocarditis of a previously normal appearing trileaflet aortic valve.
Mycotic Aneurysm of Aortic Sinus of Valsalva Aortic valve endocarditis may be complicated by ring abscess,6,7 and subaortic complications involving the mitral-aortic intervalvular fibrosa and mitral valve apparatus.8,9 Mycotic aneurysms involving the aortic sinus of Valsalva have infrequently been described.3,4,10-14 Most of the echocardiographic reports have been in subjects with ruptured right sinus of Valsalva and communication with the right atrium11,12 or right ventricle.13 Rothbart and Chahine14 reported a case of left sinus of Valsalva aneurysm that had ruptured into the left ventricle. Our case had the unusual and rare complication of mycotic aneurysm of the right aortic sinus of Valsalva. TEE clearly showed the location of the aneurysm and its communication with the main aortic lumen by a narrow orifice located at the base of the right aortic cusp. The aneurysmal cavity was patent in systole and diastole (Figures 1 and 2). There was flow out of the aneurysm into the aortic lumen in diastole (Figure 3). The systolic flow into the aneurysm was, however, not well seen. TEE permitted evaluation of anatomy and flow characteristics of this unruptured mycotic aneurysm. Takach et al3 published a surgical series of aortic sinus of Valsalva aneurysms of 129 patients. These aneurysms were related to IE in 33% of cases and occurred in association with other congenital abnormalities in the remaining (Marfan syndrome, bicuspid aortic valve, and ventricular septal defects).3 Cineangiog-
476 Batiste, Bansal, Razzouk
Journal of the American Society of Echocardiography May 2004
Figure 2 Parasternal short-axis imaging in diastole without and with color flow imaging showing trileaflet aortic valve (AV), mild central aortic regurgitation (AR) (arrowhead), and right sinus of Valsalva aneurysm (arrow). There is diastolic color flow jet related to sinus of Valsalva aneurysm. RVOT, Right ventricular outflow tract.
Figure 3 Multiple transesophageal echocardiographic images of aortic root. Upper left panel shows systolic opening of trileaflet aortic valve. Small vegetation (V) is noted at margin of left cusp (arrowhead). Sinus of Valsalva aneurysm communicated through small mouth of 2 mm (arrow) at base of right cusp to aortic lumen. Diastolic frame with color flow imaging shows diastolic jet (arrow) out of aneurysm. Bottom panel shows surgical specimen of excised left aortic (LA) cusp (L) with V. N, Noncoronary cusp; PA, pulmonary artery; R, right aortic cusp; RA, right atrium; RV, right ventricle.
raphy was used to diagnose these lesions in this report. These investigators described variable natural history of these lesions, and no guidelines were provided regarding the timing of surgical intervention. It may be prudent to perform operation on mycotic aortic sinus of Valsalva aneurysm related to endocarditis because of potential for unexpected rupture. TEE allowed evaluation of anatomy and flow characteristics of this unruptured mycotic an-
eurysm, and permitted successful surgical repair of this rare lesion.
REFERENCES 1. Harding PR, Yerkey MW, Deye G, Storey D. MARSA endocarditis secondary to tongue piercing. J Miss State Med Assoc 2002;43:109.
Journal of the American Society of Echocardiography Volume 17 Number 5
2. Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis 2002;8:850-1. 3. Takach JJ, Reul GJ, Duncan M, Cooley DA, Livesay JJ, Ott DA, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg 1999;68:1573-7. 4. Shulman R, Khuri S, Ray BJ, Paris AF. Echocardiographic features of an unruptured aneurysm of the right sinus of Valsalva. Chest 1980;77:700-2. 5. Whiley RA, Fraser HY, Hardie JM. Phenotypic differentiation of Streptococcus constellantus, Streptococcus intermedius, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infection. J Clin Microbiol 1990;28:1497-501. 6. Daniel WG, Mugge A, Martin RP, Lindert O, Hausmann D, Nonnast-Daniel B, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991;324:795-800. 7. Graupner C, Vilacosta I, San Roman JA, Ronderos R, Sarria C, Fernandez C, et al. Periannular extension of infective endocarditis. J Am Coll Cardiol 2002;39:1204-11. 8. Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis: clinical and surgical implications. Circulation 1992;86:35362.
Batiste, Bansal, Razzouk 477
9. Bansal R. Infective endocarditis. Med Clin North Am 1995; 79:1205-35. 10. Shaffer EM, Snider AR, Beekman RH, Behrendt DM, Peschiera AW. Sinus of Valsalva aneurysm complicating bacterial endocarditis in an infant; diagnosis with two-dimensional and Doppler echocardiography. J Am Coll Cardiol 1987;9:58891. 11. Chow LC, Dittrich HC, Dembitsky WP, Nicod PH. Accurate localization of ruptured sinus of Valsalva aneurysm by real time two-dimensional Doppler flow imaging. Chest 1988;94: 462-5. 12. Cooper MJ, Silverman NH, Huey E. Group A beta-hemolytic streptococcal endocarditis precipitating rupture of sinus of Valsalva aneurysm: evaluation by two-dimensional, Doppler, and contrast echocardiography. Am Heart J 1988;115: 1132-4. 13. Bansal RC, Wangsnes KM, Bailey L. Right aortic sinus of Valsalva-to-right ventricle fistula complicating bacterial endocarditis of membranous ventricular septal defect: evaluation by two-dimensional, color flow, and Doppler echocardiography. J Am Soc Echocardiogr 1993;6:308-11. 14. Rothbart RM, Chahine RA. Left sinus of Valsalva aneurysm with rupture into the left ventricular outflow tract: diagnosis by color-encoded Doppler imaging. Am Heart J 1990;120: 224-7.