Skip to main content

Advertisement

A patient with fever, chest pain and a rapidly changing chest X-ray

Article metrics

  • 605 Accesses

A 58-year-old male presented to the emergency department with fever, malaise and right-sided chest pain, aggravating during inspiration. Two days prior to presentation, he had been discharged home from another hospital with antibiotics for a suspected urinary tract infection. Chest X-ray and CT scan, trans-thoracic echocardiography and blood cultures had not revealed any abnormalities during that hospital admission. The patient had a Bentall procedure with aortic valve replacement, complicated by cardiac tamponade 2 years earlier. Since then his body weight had gradually decreased by 20 kg, and there had been intermittent low-grade fever.

The diagnosis was prosthetic valve endocarditis (PVE) with partial dehiscence of the prosthesis resulting in a contained mediastinal hematoma. The chest radiograph showed a circular paracardial structure (Fig. 1) that was not present on the chest X-ray 2 days prior to presentation. The dramatic change in the plain chest film over 2 days is suggestive of a rapidly developing false aneurysm or haemorrhage. CT scan of the chest revealed extravasation of contrast cranial to the aortic valve (Fig. 2: white arrow) with a contained hematoma in the anterior and middle mediastinum. PVE occurs with a 3–6% accumulative frequency 5 years after surgery, with the highest incidence in the first year [1]. The ~11 year probability of bleeding is 19 to 42%, occurring more frequently in mechanical valves because of the lifelong anti-coagulation [2, 3]. PVE can be treated with antibiotics alone unless there is evidence of bleeding [4], as was the case for our patient, who was admitted to the intensive care unit after replacement of the prosthesis, where he gradually recovered.

Fig. 1
figure1

Chest X-ray made during current presentation

Fig. 2
figure2

Contrast-enhanced CT scan of the chest

References

  1. 1.

    Karchmer AW (1999) In: Mandell GL et al (eds) Principles and practice of infectious diseases, 5th edn. Churchill Livingstone, Philidelphia, p 903

  2. 2.

    Hammermeister KE, Sethi GK, Henderson WG et al (1993) The Veterans Affairs Cooperative Study on Valvular Heart Disease: A comparison of outcomes in men 11 years after heart valve replacement with a mechanical valve or bioprosthesis. N Engl J Med 328:1289

  3. 3.

    Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC et al (1991) Twelve year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprosthesis. N Engl J Med 324:573

  4. 4.

    Bonow RO, Carabello BA, Chatterjee K et al (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 48:e1

Download references

Author information

Correspondence to Bas de Groot.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 2.0 International License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and Permissions

About this article

Keywords

  • Aortic Valve
  • Aortic Valve Replacement
  • Cardiac Tamponade
  • Mechanical Valve
  • False Aneurysm