Case Study

An otherwise well 53-year-old man had mitral valve prolapse diagnosed 20 years prior, and had been clinically stable. He presented with an eight-week history of night sweats and a 5-kg weight loss. Approximately one month prior to the onset of symptoms, the patient underwent a dental cleaning and took amoxicillin 2 g, 1 h prior to the procedure. The physical examination revealed a man who appeared well and whose blood pressure in the right arm in the sitting position was 118/64 mm Hg with a heart rate of 84 beats per minute (regular). His chest was clear to auscultation and his heart sounds were normal with the exception of a grade 3/6 systolic murmur radiating to the axilla. The peripheral pulses were all palpable and peripheral edema was absent. A blood culture yielded Streptococcus mutans.

A transthoracic echocardiogram revealed significant myxomatous mitral valve disease; marked thickening of the posterior leaflet with a shaggy appearance and flail segment involving predominantly the middle scallop were seen. Severe eccentric mitral regurgitation was present. The left atrium was significantly enlarged. This study was followed up with a transesophageal echocardiogram, which demonstrated that the posterior mitral valve leaflet was diffusely thickened and very redundant. There was severe prolapse of this leaflet. There was at least one small mobile mass at the leaflet tip, but the entire posterior leaflet was thickened and somewhat shaggy. The findings were consistent with endocarditis.

The S. mutans had a minimal inhibitory concentration (MIC) to penicillin of 0.008 g/mL.

Since the patient was stable, it was elected to initiate home parenteral antimicrobial therapy with penicillin G, 18 million units per day administered by continuous infusion pump for 4 weeks. The patient had an uneventful course of therapy and underwent an elective mitral valve replacement one year later.

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