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A3448 - Aorto Right Ventricular Fistula: A Rare Complication Due to Salmonella Enteritidis an Unusual Organism of Prosthetic Valve Endocarditis
Author Block: A. Gandhi1, S. Palasamudram Shekar2, A. Hadeh3; 1Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, FL, United States, 2Pulmonary and Critical Care, Cleveland Clinic Florida, Weston, FL, United States, 3Cleveland Clinic Florida, Weston, FL, United States.
Introduction: Salmonella isolates often causes human infections ranging from mild gastroenteritis to severe invasive infections especially in infants, elderly and immunocompromised hosts. Salmonella bacteremia frequently causes infected aortic aneurysm but infective endocarditis or mural endocarditis are rare complications.
Case presentation: A 64 year old male with past medical history of paroxysmal atrial fibrillation and mechanical aortic valve presents for evaluation of acute dyspnea. He recently was admitted and treated 4 weeks ago for partial small bowel obstruction complicated by small bowel micro perforation and Salmonella enteritidis bacteremia. His transthoracic echocardiogram during that admission showed a well seated mechanical aortic valve with no signs of valvular infection. He was treated with levofloxacin for 2 weeks based on culture directed data and prior to his discharge he was doing well. He returned to the emergency department for evaluation of acute dyspnea which was found to be secondary to new onset congestive heart failure. His transthoracic echocardiogram showed severe acute aortic regurgitation, dilated proximal aorta and perivalvular leak. His admission blood cultures were reported positive for Salmonella enteritidis during his readmission. He also underwent transesophageal echocardiogram which showed aorto-right ventricular fistula in addition to above mentioned valvular and aortic defects. He emergently underwent surgical repair with replacement of his mechanical valve to a new bioprosthetic aortic valve and aortic root graft placement. Post operatively he had a complete heart block necessitating a pacemaker implantation. He was eventually discharged to a skilled nursing facility for rehabilitation along with the plan to complete a 6 weeks duration of intravenous ceftriaxone.
Discussion: Salmonella endocarditis accounted for up to 2.9% of bacterial endocarditis cases, which reflects the rarity of cardiac involvement by Salmonella species. The overall prognosis of reported cases of Salmonella endocarditis was grave with a mortality rate of 42.5%. The perivalvular abscess is a rare complication of infective endocarditis which predisposes patients to severe valvular dysfunction. Aorto-cardiac fistulas are relatively rare and associated with high mortality of 55%. In conclusion, Salmonella endocarditis although rare, may involve the mitral and aortic valve or cardiac walls and is associated with a high mortality rate.
Conclusion: Salmonella endocarditis although rare may cause purulent infections in the perivalvular area or myocardium leading to substantial mortality.