Chiari Network and Aortic Valve Endocarditis with Concurrent Pulmonary and Systemic Embolization

Abstract

Graphical abstract

Complicated Infective Endocarditis Limited to a Chiari Network

“…Our patient presented with features of the complications of infective endocarditis with an initial negative TTE which was followed by a TEE, done on account of a high index of suspicion, which eventually revealed the vegetations attached solely to the Chiari network, sparing the valves on both the right and left sides of the heart. This is in contrast to many previously reported cases in which other heart valves were notably involved [ 5 , 6 ], sometimes on both sides of the heart.…”

“…The decision for the medical versus surgical approach to the treatment of Chiari network endocarditis has no set guidelines in terms of size or extent of the vegetation; however, Payne et al in 2003 described a surgical approach to a patient who already had another indication for cardiac surgery (three vessel disease requiring coronary artery bypass grafting) [3] . Complete resolution with medical therapy alone has also been described in a patient with Chiari network endocarditis also affecting the aortic valve [ 5 ], even though the dimensions of the vegetation on the Chiari network in that report were much larger, (28 × 8 mm) compared to those of our patient (8.3 × 4.6 mm).…”

“…Complications of infective endocarditis such as the multilobar lung abscesses and single brain abscess, noted in our patient, which likely occurred through hematogenous spread from the primary focus of infection on the Chiari malformation have been described in the past as well. This spread is thought to be facilitated in patients with atrial septal defects or other right-to left shunts [ 5 ] which was not demonstrated on the echocardiograms of this patient. The lack of a physically demonstrable shunt however does not preclude hematogenous spread as demonstrated in our index case.…”

“…Even though it is usually of no significance and discovered incidentally during transesophageal echocardiography for other indications or at autopsy, historical associations with some conditions such as a patent foramen ovale, with more intense right-to-left shunting than controls, atrial septal aneurysm and recurrent arterial embolic events with a cardiac source have been described in the literature [ 2 , 3 ]. Infective endocarditis affecting the Chiari network is a rare finding which has been seldom described in the literature [ 5 ], and isolated involvement of the Chiari network, while sparing the other heart valves, is clearly a much rarer entity.…”

“…It is however difficult to make definitive comments on this as it was not present on admission. It is also unlikely for Osler's nodes or Janeway lesions to resolve with topical corticosteroids without adequate treatment tailored to the causative agent of the infective endocarditis, as described in a similar case, where the skin manifestations we noted to have resolved within 8–10 weeks of therapy (a 12-week course of antibiotics had been planned for the patient in that case report on account of methicillin-resistant Staphylococcus being the causative organism) [ 5 ]. Our patient's blood cultures grew Streptococcus intermedius , sensitive to ceftriaxone, for which at least 6 weeks of antibiotic therapy was the recommended treatment approach.…”