© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12665
Echocardiography
IMAGE SECTION Section Editor: Brain D. Hoit, M.D.
Echocardiography: A Case of Coronary Sinus Endocarditis Clara Kwan, M.D.,* On Chen, M.D.,† Svetlana Radionova, R.D.C.S.,† Adnan Sadiq, M.D.,† and Manfred Moskovits, M.D.† *Department of Medicine, Maimonides Medical Center, Brooklyn, New York; and †Department of Cardiology, Maimonides Medical Center, Brooklyn, New York
(Echocardiography 2014;31:E287–E288) Key words: coronary sinus, infective, endocarditis, end-stage renal disease Case: A 23-year-old female with history of hypertension and end-stage renal disease requiring hemodialysis (HD) presented with fever. She had been undergoing HD via a tunneled catheter for a year and presented 3 months prior to this admission for bacteremia with Enterococcus faecalis. At that time she was treated with vancomycin and gentamycin as well as HD catheter replacement and implantation of an arteriovenous (AV) fistula. She was discharged to complete 10 days of intravenous vancomycin during HD and ciprofloxacin orally. She now presented with fever of 102°F during HD, laboratory findings showed a white blood cell count of 30 9 109/L, hemoglobin of 10.2 g/dL, hematocrit of 31%, and platelets of 31 9 109. Basic metabolic panel showed sodium of 134 mEq/L, potassium 5.4 mEq/L, chloride 97 mmol/L, carbon dioxide 25 mmol/L, blood urea nitrogen 81 mg/dL, creatinine 15.1 mg/dL, glucose 203 mg/dL, and calcium 8 mg/dL. Blood cultures were positive for Acinetobacter baumanii. Her fever persisted despite antimicrobial coverage with ampicillin sulbactam and gentamicin intravenously. As her AV fistula was not yet matured a HD catheter was replaced. Transthoracic echocardiogram (Philips iE33, Philips Medical Systems, Andover, MA, USA) performed revealing a mobile structure of 1.4– 0.4 cm in the right atrium, originating from the ostium of the coronary sinus (CS) consistent with vegetation. No valvular involvement was seen (Figs. 1 and 2; Videos S1–S3). Address for correspondence and reprint requests: Clara Kwan, M.D., Department of Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219. Fax: 718-283-8498; E-mail: [email protected]
Figure 1. An apical four-chamber view with posterior angulation showing a vegetation measuring 1.4 9 0.4 cm is seen in the right atrium, attached to the ostium of the coronary sinus (white arrow) consistent with a vegetation. RA = right atrium; RV = right ventricle; LV = left ventricle.
With persistent fever and echocardiographic findings, antibiotics were changed from ampicillin sulbactam to meropenem intravenously according to susceptibility. Since the diagnosis of endocarditis was established by echocardiography and her symptoms improved upon treatment of antibiotics, transesophageal echocardiogram was not required. She was discharged with 6 weeks of ceftazidime and gentamicin to be given after dialysis. Her blood cultures turned negative, fever subsided, and her white blood cell count normalized. On outpatient follow-up after completion of antibiotics, the patient had no further febrile events and no further imaging was required. Several months later, the patient underwent removal of her tunneled catheter as her AV fistula was matured for HD access. E287
Kwan, et al.
leading to endothelial damage predisposing her to develop endocarditis of the CS. Furthermore, A. baumannii is a rare cause of IE. It is found in hospital settings, intensive care units, ventilators as well as HD machines. Acinetobacter complexes are associated with higher rate of mortality due to increased virulence and resistance to antibiotic.4 In our case, antibiotics were adjusted based on sensitivity and given the response to therapy no further work up was needed. References
Figure 2. A parasternal right ventricular inflow view showing the vegetation in a different plane, it is again seen originating from the ostium of the coronary sinus and extending in to the right atrium (white arrow).
Patients undergoing HD have an increased rate of infective endocarditis (IE) due to repetitive episodes of bacteremia and an impaired immune system.1 IE most commonly affects the mitral and aortic valves, involvement of the right heart structures occurs more often in intravenous drug users and patients with indwelling instruments such as pacemaker wires. There are reports of IE of the right heart valves in patients on HD; however, there are no reported cases of CS endocarditis in this population.2 Furthermore, IE of the CS is rare with only few cases reported in the literature. Dryer et al.3 described a patient with intravenous drug abuse and IE; vegetation was found extending to the atrial endocardium and wall of the CS. The patient had no instrumentation other than the placement of HD catheters
E288
1. Jones DA, McGill LA, Rathod KS, et al: Characteristics and outcomes of dialysis patients with infective endocarditis. Nephron Clin Pract 2013;123:151–156. 2. Thakar S, Janga KC, Tolchinsky T, et al: Superior vena cava and right atrium wall infective endocarditis in patients receiving hemodialysis. Heart Lung 2012;41:301–307. 3. Dryer R, Goldman D, Nelson R: Septic thrombophlebitis of the coronary sinus in acute bacterial endocarditis. Lancet 1976;7981:369. 4. Sherrita B, Navneet L, Icilma L: Acinetobacter endocarditis presenting as a large right atrial mass: An atypical presentation. Echocardiography 2010;27:E39–E42.
Supporting Information Additional Supporting Information may be found in the online version of this article: Video S1. A modified posteriorly angulated four-chamber view revealing a vegetation in the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle. Video S2. A zoomed modified four-chamber view showing a prominent vegetation in the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle. Video S3. RV inflow view revealing the vegetation originating from the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle.
Echocardiography
IMAGE SECTION Section Editor: Brain D. Hoit, M.D.
Echocardiography: A Case of Coronary Sinus Endocarditis Clara Kwan, M.D.,* On Chen, M.D.,† Svetlana Radionova, R.D.C.S.,† Adnan Sadiq, M.D.,† and Manfred Moskovits, M.D.† *Department of Medicine, Maimonides Medical Center, Brooklyn, New York; and †Department of Cardiology, Maimonides Medical Center, Brooklyn, New York
(Echocardiography 2014;31:E287–E288) Key words: coronary sinus, infective, endocarditis, end-stage renal disease Case: A 23-year-old female with history of hypertension and end-stage renal disease requiring hemodialysis (HD) presented with fever. She had been undergoing HD via a tunneled catheter for a year and presented 3 months prior to this admission for bacteremia with Enterococcus faecalis. At that time she was treated with vancomycin and gentamycin as well as HD catheter replacement and implantation of an arteriovenous (AV) fistula. She was discharged to complete 10 days of intravenous vancomycin during HD and ciprofloxacin orally. She now presented with fever of 102°F during HD, laboratory findings showed a white blood cell count of 30 9 109/L, hemoglobin of 10.2 g/dL, hematocrit of 31%, and platelets of 31 9 109. Basic metabolic panel showed sodium of 134 mEq/L, potassium 5.4 mEq/L, chloride 97 mmol/L, carbon dioxide 25 mmol/L, blood urea nitrogen 81 mg/dL, creatinine 15.1 mg/dL, glucose 203 mg/dL, and calcium 8 mg/dL. Blood cultures were positive for Acinetobacter baumanii. Her fever persisted despite antimicrobial coverage with ampicillin sulbactam and gentamicin intravenously. As her AV fistula was not yet matured a HD catheter was replaced. Transthoracic echocardiogram (Philips iE33, Philips Medical Systems, Andover, MA, USA) performed revealing a mobile structure of 1.4– 0.4 cm in the right atrium, originating from the ostium of the coronary sinus (CS) consistent with vegetation. No valvular involvement was seen (Figs. 1 and 2; Videos S1–S3). Address for correspondence and reprint requests: Clara Kwan, M.D., Department of Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219. Fax: 718-283-8498; E-mail: [email protected]
Figure 1. An apical four-chamber view with posterior angulation showing a vegetation measuring 1.4 9 0.4 cm is seen in the right atrium, attached to the ostium of the coronary sinus (white arrow) consistent with a vegetation. RA = right atrium; RV = right ventricle; LV = left ventricle.
With persistent fever and echocardiographic findings, antibiotics were changed from ampicillin sulbactam to meropenem intravenously according to susceptibility. Since the diagnosis of endocarditis was established by echocardiography and her symptoms improved upon treatment of antibiotics, transesophageal echocardiogram was not required. She was discharged with 6 weeks of ceftazidime and gentamicin to be given after dialysis. Her blood cultures turned negative, fever subsided, and her white blood cell count normalized. On outpatient follow-up after completion of antibiotics, the patient had no further febrile events and no further imaging was required. Several months later, the patient underwent removal of her tunneled catheter as her AV fistula was matured for HD access. E287
Kwan, et al.
leading to endothelial damage predisposing her to develop endocarditis of the CS. Furthermore, A. baumannii is a rare cause of IE. It is found in hospital settings, intensive care units, ventilators as well as HD machines. Acinetobacter complexes are associated with higher rate of mortality due to increased virulence and resistance to antibiotic.4 In our case, antibiotics were adjusted based on sensitivity and given the response to therapy no further work up was needed. References
Figure 2. A parasternal right ventricular inflow view showing the vegetation in a different plane, it is again seen originating from the ostium of the coronary sinus and extending in to the right atrium (white arrow).
Patients undergoing HD have an increased rate of infective endocarditis (IE) due to repetitive episodes of bacteremia and an impaired immune system.1 IE most commonly affects the mitral and aortic valves, involvement of the right heart structures occurs more often in intravenous drug users and patients with indwelling instruments such as pacemaker wires. There are reports of IE of the right heart valves in patients on HD; however, there are no reported cases of CS endocarditis in this population.2 Furthermore, IE of the CS is rare with only few cases reported in the literature. Dryer et al.3 described a patient with intravenous drug abuse and IE; vegetation was found extending to the atrial endocardium and wall of the CS. The patient had no instrumentation other than the placement of HD catheters
E288
1. Jones DA, McGill LA, Rathod KS, et al: Characteristics and outcomes of dialysis patients with infective endocarditis. Nephron Clin Pract 2013;123:151–156. 2. Thakar S, Janga KC, Tolchinsky T, et al: Superior vena cava and right atrium wall infective endocarditis in patients receiving hemodialysis. Heart Lung 2012;41:301–307. 3. Dryer R, Goldman D, Nelson R: Septic thrombophlebitis of the coronary sinus in acute bacterial endocarditis. Lancet 1976;7981:369. 4. Sherrita B, Navneet L, Icilma L: Acinetobacter endocarditis presenting as a large right atrial mass: An atypical presentation. Echocardiography 2010;27:E39–E42.
Supporting Information Additional Supporting Information may be found in the online version of this article: Video S1. A modified posteriorly angulated four-chamber view revealing a vegetation in the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle. Video S2. A zoomed modified four-chamber view showing a prominent vegetation in the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle. Video S3. RV inflow view revealing the vegetation originating from the coronary sinus. RA = right atrium; RV = right ventricle; LV = left ventricle.
