Case Presentation:
A 65-year-old female was brought to an outside hospital with complaints of word-finding difficulties and altered mental status for two days. Her past medical history was notable for hypertension, dyslipidemia, multiple previous cerebrovascular accidents without any residual deficits, peripheral vascular disease, atrial fibrillation on Apixaban, coronary artery bypass grafting (CABG) with bio-prosthetic mitral valve (BPMV) replacement and left atrial appendage ligation six years ago. She was afebrile on presentation and had no other neurological deficits on her exam. Blood work indicated mild leukocytosis of 11.4 x103 uL (reference 4.5–11), urine analysis, and culture was negative for infection. Computed tomography (CT) of the head showed multiple small old infarcts. Head and neck computed tomography angiography (CTA) revealed no evidence of large vessel occlusion or critical stenosis. Echocardiography showed an ejection fraction of 70% and a large echo density on the posterior part of the BPMV on the ventricular side. She was transferred to our facility for further evaluation of the mass. TEE showed a #25 Carpentier Edwards’s BPMV with a large echogenic mass measuring 2.6 cm x 1.7 cm attached to the ventricular side of the mitral annulus (Figures 1 and 2). From the echotexture, location, and size, it appeared to be more likely a neoplasm than vegetation. The mean gradient across the valve was 7 mm Hg, and the valve area by three-dimensional planimetry was 2 cm2. Post-TEE patient had worsening leukocytosis to 21x103 ul, which prompted consult with an infectious disease specialist who recommended blood cultures. Growth ofStreptococcus Gordonii was noted in 4/4 culture bottles. She was started on intravenous (IV) ceftriaxone 2g per 24 h with gentamicin 3mg/kg every 48 h for synergy. Repeat blood cultures were negative. Subsequent brain magnetic resonance imaging (MRI) showed multiple small acute infarcts in the left posterior parietal lobe. The patient underwent excision of Mitral annular mass along with redo mitral valve replacement and CABG x 1 after completion of two weeks of antibiotics. The patient had an uneventful postoperative recovery. While the surgeon described the mass as suspicious for myxoma, subsequent pathology was notable for fragments of material consisting of fibrin, thrombus, and acute inflammation, consistent with vegetation. No vegetation was identified on the cusps of the BPMV specimen.