Case Presentation: 60 y/o African American male with h/o chronic esophageal strictures s/p multiple esophageal dilations presented to the ER with complaints of weakness and dizziness. He met criteria for sepsis with possible source as aspiration pneumonia and was started on broad spectrum antibiotics. Two sets of blood cultures done from admission grew Streptococcus mitis/oralis. Antibiotic coverage was narrowed based on susceptibility results to IV Ceftriaxone. Infectious disease was consulted to assist with workup and management of bacteremia. There was a high suspicion of endocarditis, however the patient did not meet all the DUKE criteria for endocarditis. He had no murmur, Janeway lesions, or Osler nodes but he did have poor dentition. Transthoracic echocardiogram (TTE) was obtained which showed moderate to severe aortic valve insufficiency but no clear presence of valvular vegetations. A calcified mass posterior to left atrium was seen which was thought to represent calcification of the thoracic aorta. Transesophageal echocardiogram (TEE) was unable to be done to rule out endocarditis due to patient having an esophageal stent.  Chest CT was done to assess for possible para-esophageal fluid collections which revealed mass-like thickening of anterior mitral valve leaflet concerning for endocarditis. Cardiology and Cardiothoracic surgery were consulted and patient underwent intracardiac echocardiogram (ICE) which showed large abscess and aneurysmal changes involving the mitral valve along with clear vegetation involving the aortic valve.  Patient underwent pre-op testing including panorex which showed possible dental abscess. Oral and maxillofacial surgery was consulted and did not recommend extraction since there were no clinical signs of dental abscess. Patient subsequently underwent replacement of aortic and mitral valves. Pathologic evaluation of the valves was consistent with endocarditis. Cultures of the valves were negative since patient had been on appropriate antibiotic treatment. Patient was discharged on six weeks of Ceftriaxone.

Discussion: Infective endocarditis is a common diagnosis on the differential for causes of bacteremia. TTE is the initial study to aid in the diagnosis of endocarditis and TEE is usually performed subsequently to definitively rule out endocarditis when clinical suspicion remains high. When TEE is contraindicated due to presence of esophageal stricture, less commonly utilized imaging modalities such as ICE can be attempted. In one study, ICE was found to have sensitivity of 100% in detecting endocarditis as compared to TEE1.

Conclusions: This case illustrates an atypical case of endocarditis involving both aortic and mitral valves which was detected by CT of the chest initially and confirmed with ICE due to his unique anatomy when TEE was contraindicated. It is important for hospitalists to be knowledgeable about different diagnostic modalities available to confirm endocarditis in a patient where TEE is contraindicated.

1.  Narducci ML, Pelargonio G, Russo E, Marinaccio L, Di Monaco A, Perna F, et al. Usefulness of intracardiac echocardiography for the diagnosis of cardiovascular implantable electronic device-related endocarditis. Journal of the American College of Cardiology. 2013;61(13):1398–405.