ST-elevation myocardial infarction (STEMI) is a rare and potentially fatal complication of infective endocarditis. We report the ninth case of embolic native aortic valve infective endocarditis causing STEMI and the first case to describe consecutive embolisms leading to infarctions of separate coronary territories. Through examination of this case in the context of the previous eight similar documented cases in the past, we find that infective endocarditis of the aortic valve can and frequently affect more than a single myocardial territory and can occur consecutively. Further, current treatment modalities for embolic infective endocarditis causing acute myocardial infarction are limited and unproven. This index case illustrates the potential severity of complications and the challenges in developing standardized management for such patients.
Infective endocarditis as a result of injection drug use is an increasingly prevalent condition in the United States [
A 31-year-old female with a past medical history of intravenous drug abuse (IVDA) presented with a four-day history of generalized weakness, shortness of breath, and chest pain. She described her chest pain as pleuritic and associated with a nonproductive cough. She also reported fevers with diffuse body and joint pains. The patient injected heroin daily but denied any other substance abuse. On arrival to the emergency department, the patient was afebrile, tachycardic, normotensive, and saturating well on room air. Physical exam was significant for a chronic appearing left lateral forearm wound that was approximately five by five centimeters without drainage or significant erythema. Another chronic appearing wound was found on the left lateral calf that was approximately five by seven centimeters with several foci of purulent drainage with edema and erythema of the surrounding area. Imaging later revealed a five by twelve by ten millimeter abscess in the left lateral calf. She had multiple stigmata of injection drug use along her bilateral upper and lower extremities. On this encounter, the patient was admitted for treatment of sepsis secondary to cellulitis but elected to leave against medical advice from the emergency department and was provided with a course of doxycycline and sulfamethoxazole-trimethoprim. One day following the encounter, blood cultures drawn at the time of the encounter grew methicillin-resistant Staphylococcus aureus (MRSA).
Three days following the initial encounter, the patient again presented to the emergency department. Upon arrival, the patient was confused with nonsensical speech and was unable to provide medical history. She was febrile at 39.4°C. Physical examination was notable for pale conjunctiva, jugular venous distension, tachypnea, tachycardia, a one out of six systolic ejection murmurs at the right upper sternal border, and extensive skin wounds as described prior.
The patient is with a past medical history of intravenous drug use.
Initial blood work of the second encounter was significant for a white blood cell count of 33.1 k/
Infective endocarditis Cellulitis, abscess Opioid overdose Drug-induced vasospasm
An electrocardiogram performed on arrival demonstrated an anterolateral STEMI (Figure
Electrocardiogram performed on patient arrival demonstrating ST-elevation in leads V3-V4.
Echocardiogram demonstrating a vegetation measuring
Echocardiogram demonstrating a vegetation proximal to the left aortic cusp (a) and the vegetation mobilizing toward the left coronary artery origination anastomosis upon valve opening (b).
The patient was started on vancomycin, piperacillin, tazobactam, and ceftriaxone. Acute cardiac intervention, which would have required transfer to a tertiary care center with cardiothoracic surgery capabilities, was deferred due to the patient’s unstable hemodynamic state and comorbid conditions. A repeat electrocardiogram five hours later as the patient became more hypotensive revealed evolution of anterior MI with diffuse Q waves and an inferior lead STEMI (Figure
Electrocardiogram performed five hours after first electrocardiogram (Figure
There are few documented cases of acute myocardial infarction caused by IE particularly of the aortic valve. In IVDA patients, infective endocarditis most frequently affects tricuspid valves (50%) and aortic (20%) and mitral valves (20%) less frequently [
There are eight previously documented cases of ST-elevation myocardial infarctions caused by embolic native aortic valve endocarditis [
Current treatment modalities for embolic infective endocarditis causing acute myocardial infarction are limited and unproven. Detailed guidelines for managing STEMI and for managing infective endocarditis as separate conditions exist but recommendations for concurrent diagnoses are lacking. The treatment modalities applied in the nine cases of STEMI caused by embolic aortic valve endocarditis varied considerably, as did the affected patient characteristics and associated outcomes. Of the nine cases, three underwent angioplasty; two of the three were reported to survive beyond the immediately observed period [
Due to the rarity of this case, we consider possible predisposing factors as well as an alternative explanation to this presentation. Rather than two distinct emboli affecting different vessels, it is necessary to consider the possibility that a single embolus propagated through a wrap-around left anterior descending (LAD) artery supplying both the anterior and inferior cardiac territories. Indeed, such a scenario could feasibly present as consecutive STEMI of different coronary myocardial territories. However, while a definitive answer attained through perhaps a coronary angiogram is not available in this case, we believe the presented electrocardiograms and echocardiogram support that there were indeed two distinct emboli. First, in the initial electrocardiogram (Figure
Among the reported cases of infective aortic valve endocarditis causing embolic acute myocardial infarction, we present the first case with consecutive infarctions involving separate myocardial territories. This index case illustrates the potential severity of complications and the challenges in developing standardized management for such patients. Through this case, we hope to expand the fund of knowledge and judicious approach for similar future patients.
The authors declare that they have no conflicts of interest.