We report a case of Gemella morbillorum mitral bioprosthetic valve endocarditis with perivalvular extension in a 44-year-old human immunodeficiency virus-positive man who is an active intravenous drug user together with review of all published cases. This is only the second reported case of Gemella morbillorum endocarditis in a patient with a prosthetic valve. CASE REPORTA 44-year-old human immunodeficiency virus-positive man with a history of active intravenous drug use and a mitral valve replacement only 9 months earlier for native-valve endocarditis due to Staphylococcus aureus was admitted complaining of pleuritic chest pain, shortness of breath, fever, and chills.Physical examination revealed a temperature of 99.8°F, blood pressure of 114/70 mm Hg, a regular heat rate at 98 beats per min, and a grade III/VI holosystolic murmur radiating to the axilla. No clinical signs of congestive heart failure (such as pulmonary rales or peripheral edema) were noted.An electrocardiogram was notable for a first-degree atrioventricular block (an increased PR interval of 0.22 s) and nonspecific T wave changes. Laboratory investigations were significant for a normocytic anemia with a hemoglobin level of 10.9 g/dl and an elevated erythrocyte sedimentation rate of 108 mm per h. However, neither the total white blood cell count nor the percentage of banded neutrophils was elevated (3.72 ϫ 10 9 /liter and 4% bands, respectively). Three sets of blood cultures were obtained prior to initiating antibiotic therapy. Blood samples were incubated in a continuous-monitoring culture system (Bac T/Alert; Becton Dickinson, Organon Teknika, Durham, N.C.) at 37°C. After 24 h of incubation, growth in the anaerobic bottle was noted. The samples were then subcultured at 37°C on MacConkey's agar, sheep blood agar, anaerobic CDC blood agar, and chocolate agar incubated in CO 2 .After 24 h of subculture incubation, an alpha-hemolytic organism grew on all plates except the MacConkey agar. The organism was further characterized as being a gram-positive coccus that was both catalase and bile solubility negative.These initial findings suggested that the organism was Streptococcus viridans. However, on further evaluation with an API 20 streptococcus identification system (Bio Merieux, Vitek Inc., Hazelwood, Mo.), the organism was identified as Gemella morbillorum with 98% confidence.Antimicrobial susceptibility by disk diffusion method showed the organism to be sensitive to ceftriaxone, clindamycin, levofloxacin, tetracycline, and vancomycin, while the Etest showed sensitivity to penicillin G.A transthoracic echocardiogram revealed severe regurgitation through incompetent leaflets of the bioprosthetic mitral valve. On spectral Doppler recording of the prosthetic inflow, a severely elevated mean diastolic gradient of 22 mm Hg at a sinus heart rate of 75 beats per min was noted. Since there were no echocardiographic signs of prosthetic stenosis (the pressure half-time was only 77 ms), this gradient was indicative of severely elevated left atrial pressure...

Extrinsic compression of the left atrium is a potentially life-threatening but unusual cause of congestive heart failure. Achalasia is a motility disorder characterized by impaired relaxation of the lower esophageal sphincter and dilation of the distal two-thirds of the esophagus. We report only the third known case in the world literature of massive left atrial compression by a dilated esophagus in a patient with achalasia. The use of contrast echocardiography with perflutren protein-type A microspheres allowed for differentiation between a compressive vascular structure and the esophagus. This resulted in prompt treatment leading to hemodynamic stability after nasogastric decompression and Botulinum toxin injection at the gastroesophageal junction.

W e report a case of a patient with quadricuspid aortic valve (QAV), a rare isolated congenital abnormality, found incidentally on a transthoracic echocardiogram (TTE) ordered for a clinically unrelated indication. Our patient had a less common QAV variant, with four equal-sized cusps. Although it is believed that this QAV variant is more likely to have preserved valvular function, our patient nonetheless had moderate aortic regurgitation.A 55-year-old woman was admitted to the intensive care unit following a suicide attempt. She had jumped out of a third-story window, suffered multiple bone fractures, and later developed deep venous thrombosis in her right leg. A TTE was ordered to evaluate the right ventricular function when bilateral pulmonary emboli were visualized on computed tomography. TTE revealed that the global right ventricular systolic function was preserved despite significant pulmonary hypertension (50 mm Hg as assessed by the peak velocity of the tricuspid regurgitant jet). Left atrium and left ventricular size and function were normal.Color Doppler imaging demonstrated moderate aortic regurgitation. No apparent aortic valve (AV) leaflet abnormalities were seen on the parasternal long axis; however, the short-axis view showed four AV cusps of equal size in both systole and diastole. At end diastole, the commissural lines formed by the adjacent AV cusps resulted in an "X" configuration rather than the "Y" configuration of the normal tricuspid AV (Figure 1 and Figure 2). In addition, there was incomplete coaptation of the AV leaflets, resulting in a regurgitant orifice located in the center of the AV.Based on these findings, the diagnosis of congenital QAV was established. Antibiotic prophylaxis before bacteremia-induced procedures and annual echocardiograms were recommended. One year later, the patient is asymptomatic and no longer has pulmonary hypertension. DISCUSSIONOur case demonstrates the typical way in which the QAV is diagnosed, namely as a rare isolated asymptomatic congenital abnormality found incidentally on a TTE ordered for a clinically unrelated indication.In 1862, Balington 1 described the first case of QAV on autopsy. The reported incidence is between 0.008% (two cases in 25,556 necropsies) 2 and 0.013% (eight cases in 60,446 echocardiograms). 3 Its true incidence may be underestimated, however, because QAV may be overlooked unless it is specifically sought. QAV may be more prevalent in men than women (1.6:1.0). 4 The overall incidence of QAV is much less than that of other congenital abnormalities affecting the number of AV cusps. Bicuspid AV, the most common congenital cardiac abnormality in humans, occurs in approximately 0.9%-2% of all live births, 5 while the unicuspid AV has a reported incidence of 0.02%. 6 Interestingly, quadricuspid pulmonary valves are nine times more common than AVs. 7 The four cusps of QAV are referred to as posterior, left coronary, right coronary, and anterior supernumerary cusp. They vary in size, thickness, and pliability. Hurwitz and Roberts 8 have de...