A 28-year-old Chinese man was admitted to our hospital because of fever, chills and rigors, asthenia, malaise, cough, shortness of breath, edema and wasting for three days. His past medical history included an admission to the hospital 3 months ago due to bilateral pneumonia. At that time, the patient had intermittent, moderate grade fever, associated with chills and rigors. The fever was temporarily relieved with antipyretics. Laboratory studies showed white blood cells 12220/mm3 (82% neutrophils). Chest computed tomography demonstrated multiple patches high density in the upper right lung, multiple nodular high density in the lower right lung, a thick-walled cavity in the lower left lung, several swollen soft tissue shadows in the mediastinum, and an enlarged spleen. A transthoracic echocardiogram (TTE) showed VSD, ASD, DCRV with anomaly hypertrophied muscle bands in right ventricular outlflow tract (RVOT), continuous-wave Doppler study demonstrated a peak systolic gradient of 72 mmHg across the RVOT, trace tricuspid valve regurgitation, the thickened pulmonary valve and left ventricular ejection fraction (EF) of 57%. The diagnoses of pneumonia, congenital heart disease of VSD, ASD and DCRV were made. He was treated with cefminox sodium 2 g iv q12 h. He was afebrile in 72 h, and 14 days later he was discharged home in good condition. After discharge, the patient experienced intermittent, moderate fever and was treated with oral antibiotics. He had been complaining of edemas of lower extremities, wasting and 15-kg weight loss of 3 months’ duration.
On admission, the patient was febrile (38.3 °C), tachypnoic, anxious, and tachycardic with a heart rate of 110 bpm. His blood pressure was 120/80 mmHg. The patient was fully conscious with normal neurological examination. Auscultation of the chest was clear bilaterally without any adventitious sounds. There was a systolic murmur at the left sternal border and a diastolic murmur in the pulmonary valve area. An electrocardiogram revealed sinus tachycardia. Laboratory studies showed the following pathological values: hemoglobin 91 g/L, white blood cells 7100/mm3 (82% neutrophils), platelet count 88 000/mm3, albumin 28.9 g/L.
A repeat TTE (Fig. 1) revealed a vegetation of 18 × 4 mm on the pulmonary valve with moderate pulmonary valve regurgitation, VSD, ASD and DCRV, and the other valves were unremarkable. Normal size of left ventricle was noted with an left ventricular EF of 54%. Three sets of blood cultures (each set contained one aerobic and one anaerobic vial) were obtained over a period of 24 h. Intravenous ceftriaxone and diuretics were initiated. After 2 days of treatment he became afebrile. On the third day of admission, all the three cultures grew alpha-hemolytic, catalase-negative Gram positive cocci. Susceptibility testing of the organism was done using the disc diffusion method. On the seventh day of admission, all of the three collected blood cultures (6 vials) grew G. morbillorum. The organism isolated was highly sensitive to penicillin, ceftriaxone, rifampicin, vancomycin and ciprofloxacin and therefore the above regimen was continued. On the eighth day of admission the patient’s clinical condition got worse with aggravated exertional fatigue and dyspnea, and TTE demonstrated severe pulmonary valve regurgitation. In light of these findings and the patient’s worsening clinical manifestations, a decision was made for urgent surgical treatment.
The surgical approach was via median sternotomy. After systemic heparinization, cardiopulmonary bypass (CPB) was instituted via ascending aortic and bicaval cannulation. After aortic cross-clamping, cardiac arrest was achieved through antegrade administration of cold blood cardioplegic solution. The perimembranous VSD (0.5 × 0.4 cm), ASD (0.5 × 0.6 cm) were repaired via an oblique right atriotomy. Tricuspid valve was normal, while left and right valve leaflets of the pulmonary valves were severely destructed with a large vegetation on the anterior leaflet of pulmonary valve observed. The leaflets of pulmonary valve and vegetation were excised (Fig. 2), and DCRV was corrected through pulmonary valve and tricuspid valve followed by fixation of aortic bioprosthetic valve into the pulmonic valve annulus. Anomalous septal and parietal muscle bundles seen in RVOT divided the right ventricle into a proximal high-pressure chamber and a distal low-pressure chamber, and they were carefully resected during surgery. The main pulmonary artery was then widened with a pericardial patch. The patient was rewarmed and successfully weaned from CPB.
The patient’s recovery was uneventful, while his temperature increased abruptly to 39.5 °C on the post-operative day 4. Laboratory studies showed white blood cells 20200/mm3 (89.7% neutrophils). Blood cultures with three separate blood specimens were obtained. In addition to previous medications, vancomycin 2 × 1 g/day IV was added. He became afebrile in 2 days with the combination of antibiotics. Vancomycin was discontinued in 1 weeks, while ceftrixone was continued. Subsequent blood cultures showed negative. Culture of the excised tissue specimen was also negative for bacteria. The patient received 4 weeks antibiotic treatment and recovered well after surgery. He was discharged in good condition and remained asymptomatic at his 3-month follow-up.
