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Cover Figure


Clinical vignette

Primary mural endocarditis

Peadar F. McKeown1*, Patrick M. Donnelly2, and Daniel J. Flannery1

1Cardiology Department, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ, UK and 2Belfast City Hospital, 51 Lisburn Road, Belfast, BT9 7AB, UK

*Corresponding author. Tel: +44 2838334444; fax: +44 2838394802. E-mail address: peadar.mckeown@ntlworld.com

A 57-year-old male was admitted with a 2-week history of fever, rigours, and confusion and a single episode of retrosternal chest pain. He had recently undergone a circumcision. Clinical examination revealed a temperature of 38.3°C and a balanitis. Urinanalysis revealed haematuria and proteinuria. He had acute renal failure (urea 24.5 mmol/L, creatinine 341 µmol/L) and an elevated C-reactive protein (356 mg/L). Twelve-lead electrocardiograph demonstrated anterolateral T-wave inversion and troponin T was elevated (0.176 ng/mL), suggesting an acute coronary syndrome. Ultrasound of renal tracts was normal. Group B haemolytic Streptococcus was isolated from both blood cultures and from swabs of his balanitis. Trans-thoracic and trans-oesophageal echocardiography demonstrated normal left-ventricular systolic function and an echo dense irregular mass at the apex of the left ventricle (Panel A) but no valvular abnormality. Computed tomography (CT) of brain revealed an infarct adjacent to the right caudate nucleus (Panel B). A radio-labelled isotope white cell scan demonstrated focal uptake at the apex of the left ventricle (Panel C). A diagnosis of mural endocarditis with coronary and cerebral embolization was made. Despite appropriate antibiotic therapy, a left ventricular apical myomectomy was required because of his continuing clinical deterioration. Surgical excision and pathological examination confirmed this rare occurrence.

Mural endocarditis in the absence of pre-disposing factors is extremely rare. This condition is usually fatal; however, our patient was fortunate to survive and make a full recovery.

Panel A. Echocardiogram demonstrating apical vegetation. LV, left ventricle; RV, right ventricle.

Panel B. CT scan of brain demonstrating an infarct adjacent to the right caudate nucleus.

Panel C. Radioisotope-labelled white cell scan with focal uptake at the apex of the left ventricle.

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