Aortic Root Abscess Presenting as Pyrexia of Unknown Origin and the Importance of Echocardiography

Aortic root abscess in patients with aortic endocarditis is not uncommon. Aortic root abscess may cause persistent sepsis, worsening heart failure, conduction abnormalities, fistula formation, and an increased need for surgery. We present a young patient with aortic root abscess presenting as pyrexia of unknown origin. She had acute severe aortic and mitral regurgitation which produced very soft murmurs that were easily missed. This report reiterates that a high index of suspicion is needed in suspecting valvular endocarditis as well as a comprehensive transthoracic and transesophageal echocardiographic examination to diagnose complications like aortic root abscess. 1. Introduction Aortic root abscess in patients with aortic endocarditis is not uncommon. Aortic root abscess may cause persistent sepsis, heart failure, conduction abnormalities, fistula formation, and an increased need for surgery. We present a young patient with aortic root abscess presenting as pyrexia of unknown origin that was diagnosed by echocardiography. 2. Case A 26-year-old female with no past medical problems was admitted to critical care unit of our hospital with history of intermittent high-grade fever (39-40°C) for 3-week duration. She was extensively investigated in other hospitals with results yielding negative blood culture, autoimmune profile, and immunodeficiency profile. She was diagnosed to have pyrexia and sepsis of unknown origin. She had received multiple antibiotics during this period from other hospitals. Apparently previous cardiac examination was normal. Clinically she was febrile, tachycardic, tachypneic, and hypotensive. Chest X-ray showed pulmonary edema. Careful clinical examination revealed elevated jugular venous pressure, soft aortic early diastolic murmur, and a soft pan systolic murmur at apex. ECG showed sinus rhythm with normal PR interval. An urgent bedside transthoracic echocardiogram (TTE) revealed dilated left ventricle, large vegetation attached to base of anterior mitral leaflet with severe mitral and aortic regurgitation with EF 45%. The aortic valve looked edematous, but no clear-cut aortic root abscess was seen. The valves were thickened suggesting rheumatic etiology. Laboratory investigations revealed anemia, leucocytosis with markedly elevated inflammatory markers. She was immediately shifted to OR, and a transesophageal echocardiogram (TEE) confirmed TTE findings. In addition there was an aortic root abscess behind the noncoronary cusp (Figure 1) along with perforation of anterior mitral leaflet with severe aortic and mitral regurgitation