SPC365

First impressions may be misleading – a case of severe aortic regurgitation

Session: MELHORES CASOS CLÍNICOS
Speaker: Inês Miranda

Congress: CPC 2025
Topic: A. Basics
Theme: 02. Clinical Skills
Subtheme: ---
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Inês Pereira de Miranda; Carolina Pereira Mateus; Manuel Ribeiro; Márcio Madeira; Maria Resende; José Pedro Neves; Filipa Gerardo; Mara Sarmento; Rodrigo Brandão; Miguel Santos; João Augusto
<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px"><strong>Presentation</strong><br />
A 53-year-old caucasian male with hypertension and psoriasis presents to the emergency department with altered mental status, dyspnea, cyanosis, mild chest pain and limb edema. There was a history of fatigue and shortness of breath over the past week.</span></span></p>

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<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px"><strong>Clinical examination and investigations</strong><br />
Physical examination showed blood pressure of 164/60mmHg, diffuse lung crackles, severe peripheral edema and compromised distal perfusion. Arterial blood gas showed a pH of 7.23 (N: 7.35-7.45), decreased bicarbonate of 7mEq/L, elevated lactates (14 mmol/L) and PaO2/FiO2 131. Hemoglobin was within normal range, creatinine of 1.8mg/dL (N: 0.7-1.2), and there were signs of hepatocellular injury (AST 334, ALT 372, GGT 249, ALP 258 U/L), elevated C-reactive protein (CRP) of 11mg/dL and NT-proBNP of 15959 pg/mL.&nbsp;ECG showed&nbsp;sinus tachycardia.</span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Transthoracic echocardiogram (TTE) showed a dilated left ventricle with ejection fraction 42% and severe aortic regurgitation. There were doubts regarding the presence of a vegetation in the aortic valve (figure 1 A, C and D). Head CT showed no significant findings. Thoraco-abdomino-pelvic CT scan revealed bilateral lung consolidations.</span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Aortic valve endocarditis (plus acute pneumonia) was presumed and patient was started on empirical antibiotic treatment with ampicillin 12g/daily, flucloxacillin 12g/daily, ceftriaxone 4g/daily for 39 days and gentamicin 180mg/daily for 14 days.</span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Transesophageal echocardiogram (TEE) days later revealed gross aortic valve destruction with severe aortic valve regurgitation. No vegetation was seen. There was an aortic root aneurysm measuring 50mm (figure 1 B, E and F).&nbsp;</span></span><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Coronary angiography showed a right coronary ostial lesion of 50% in the setting of probable aortitis.</span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Surgical aortic valve replacement with a mechanical aortic St Jude Regent 23 prothesis was performed. Aorta and aortic arch were replaced by a conduct. </span></span><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Etiological investigation showed multiple blood cultures (&gt;10) - all negative, including slow-growing microorganisms. Brucella, Coxiella and Bartonella serologies were negative, as well as tropheryma whipplei PCR. HIV was negative. Pneumococcus and legionella antigenurias were negative as well. VDLR and TPHA search was positive, leading to the diagnosis of syphilis. Lumbar puncture was positive for TPHA.</span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">Final diagnosis of syphilis was assumed with aortitis and contiguous involvement of the aortic valve that led to severe aortic regurgitation. Patient was given IV penicillin for neurosyphilis treatment and discharged in NYHA I.</span></span></p>

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<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px"><strong>Final diagnosis and take-home messages</strong></span></span><br />
<span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12px">In cases of severe aortic valve destruction with suspected endocarditis but no identified agent, it is important to think beyond the most common causes. In this case, the presence of concomitant aortic aneurysm and aortitis raised suspicion of the confirmed diagnosis of syphilis as the main contributor to the aortic valve disease.</span></span></p>