Giant basilar aneurysm in the course of subacute bacterial endocarditis.

Abstract

We describe a man aged 42 years with mitral valve regurgitation who suffered from subacute bacterial endocarditis caused by Streptococcus morbillorum. The clinical picture began with a toxic syndrome. Five months later, the patient had an embolic episode and a right rostral pontine stroke, which was followed a few days later by an adversive focal seizure on the right. Despite antibiotic treatment, he suffered complete third nerve palsy. Arteriography, magnetic resonance imaging, and computed tomography of the brain showed a giant aneurysm in the rostral end of the basilar artery; the aneurysm was clipped. We discuss the clinical features, radiology, and characteristics of this aneurysm as a unique case of a giant bacterial aneurysm in the vertebrobasilar system. ; brain stem localization is rare. Mycotic aneurysm is the next most frequent complication of endocarditis, appearing mainly in the distal branches of the middle cerebral artery. Case ReportOur patient was a 45-year-old man with a medical history of moderate mitral regurgitation. He was a heavy drinker and smoker (40 cigarettes/day) and had gout. Five months before admission, he began a toxic syndrome with joint pain, asthenia, anorexia, weight loss of 8-10 kg, and anemia. He came to our hospital with an acute picture consisting of dizziness, vomiting, instability, pulsatile left oculofrontal headache, left gaze diplopia, left hemiparesis, and left hemifacial paresthesias. He had a normal arterial blood pressure, a normal body temperature, and a systolic murmur at the cardiac apex and the left sternal border that radiated into the axilla and the base of the heart. The neurologic examination showed a dysarthric patient with a right horizontal gaze paresis and a right internuclear ophthalmoplegia that led to the one-and-a-half syndrome, 6 a vertical nystagmus appearing during upward gaze, a left hemiparesis (facial 3/5, arm 3-4/5, and leg 4/5) with the plantar reflexes in flexion, a left cerebellar deficit, and left arm and face sensory loss.An initial nonenhanced computed tomogram (CT scan) of the brain was normal (Figure 1). The results of urine and blood analyses were normal except for an erythrocyte sedimentation rate of 113 mm/hr; hematocrit was 31%, hemoglobin was 10.2 g/dl, leukocyte count was 11,290/mm 3 , platelet count was 431,000/mm 3 , and fibrinogen concentration was 405 mg/100 ml. A chest roentgenograph showed cardiomegaly due to enlargement of the left chambers. The electrocardiogram was normal with a QRS axis of -30°.On the sixth day of hospitalization, the patient began to have a severe occipital headache and later developed a focal seizure on turning his head and eyes to the right, followed by a secondary generalized tonic-clonic seizure.His leukocyte and platelet counts rose to 18,910/mm 3 and 591,000/mm 3 , respectively, and Streptococcus morbillorum grew in six blood cultures. An echocardiogram demonstrated the presence of vegetations in the mitral valve with severe mitral regurgitation, minimal tricuspid regurgitation, and enlargement...

Infective Endocarditis Caused by an Indigenous Bacterium. (Gemella morbillorum)

“…To our knowledge, only 8 cases of IE caused by Gemella morbillorum have been published including the present case. Under the genus Streptococcus, 4 cases were reported (4,5,7,8 In general, development of IE is determined by relationship between its bacterial toxicity and host immunity. Although the presence of underlying heart disease is common,IE can develop without any underlying heart disease if host immunity is disordered.…”

Endocarditis Due to Rare and Fastidious Bacteria

“…A low-grade intermittent fever was reported in all patients, and a new or recently modified cardiac murmur was reported in two-thirds of patients. Embolic manifestations were observed, with 6 of 27 patients reported to have kidney abscesses (152), spondylodiscitis (39), pneumonia (2,196), arthritis (204), or cerebral mycotic aneurysm (34). Echocardiography showed vegetations in two-thirds of patients or reports of valve abnormalities or dysfunction.…”

Brain magnetic resonance findings in infective endocarditis with neurological complications

“…[8][9][10][11][12][13][14][15][16][17] A multinational prospective study of intracranial complications in patients with infective endocarditis (IE) showed an overall cerebral embolization rate of 4%-14% in the IE cases. Moreover, 47% of the IE patients had neurological complications, with cerebral embolization representing the most frequent intracranial complication.…”