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Kingella-infective endocarditis resulting in a perforated aortic root abscess and fistulous connection between the sinus of Valsalva and the left atrium in a child

Published online by Cambridge University Press:  26 April 2010

Amichay Rotstein ,
Igor E. Konstantinov  and
Daniel J. Penny
Amichay Rotstein
Affiliation:
Department of Cardiology, The Royal Children’s Hospital, Melbourne, Australia
Igor E. Konstantinov
Affiliation:
Departments of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Australia
Daniel J. Penny*
Affiliation:
Department of Cardiology, The Royal Children’s Hospital, Melbourne, Australia
*
Correspondence to: Professor D. J. Penny, MD, PhD, FRACP, MHA, Director of Cardiology, The Royal Children’s Hospital, 50 Flemington Road, Parkville, VIC, 3052, Melbourne Australia. Tel: +613 93455922; Fax: +613 93456001; E-mail: dan.penny@rch.org.au
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Abstract

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Keywords

Aortic regurgitationmitral valveheart failure
Type
Images in Congenital Cardiac Disease
Information
Cardiology in the Young , Volume 20 , Issue 3 , June 2010 , pp. 332 - 333
Copyright
Copyright © Cambridge University Press 2010

A previously well 2-year-old boy with no known cardiac disease presented with a 5-day history of fever and acute cardiac failure. On physical examination he was found to be tachycardic with wide pulse pressure, collapsing femoral pulses, and an early diastolic murmur. Transthoracic echocardiogram showed acute endocarditis of the aortic valve with severe regurgitation, an aortic root abscess, and mitral regurgitation. Preoperative transoesophageal echocardiogram in the long-axis view (Fig 1), during emergency surgery, showed perforation of the abscess, with a fistulous connection between the left sinus of Valsalva and the roof of the left atrium (arrows) and moderate mitral regurgitation. In the short-axis view (Fig 2), the fistula could be identified in the left atrium, as could flow from the aorta. Surgical findings showed severe destruction of the left and non-coronary cusps, a perforated aortic root abscess with a fistula to the left atrium, and infection of the base of the anterior leaflet of the mitral valve. The patient underwent debridement of the abscess and replacement of the aortic root with a homograft. A pericardial patch was used to close the roof of the left atrium and reconstruct the anterior leaflet of the mitral valve.

Figure 1 Pre-operative transoesophageal echocardiogram demonstrating long-axis view of the aortic valve, aortic root abscess, and fistulous connection to the left atrium.

Figure 2 Pre-operative transoesophageal echocardiogram demonstrating short-axis view of the fistula in the left atrium with flow demonstrated in the fistula.

Results of blood cultures were positive for Kingella kingi after the operation.

At 9-month review after the episode he is home and free of cardiac symptoms.

K. kingi is now recognised as an emerging pathogen in the paediatric population and, as illustrated by this case, may cause severe acute infective endocarditis.Reference Yagupsky1

References

1. Yagupsky, P. Kingella kingae: from medical rarity to an emerging paediatric pathogen. Lancet Infect Dis 2004; 4: 358–367.CrossRefGoogle Scholar
Figure 0

Figure 1 Pre-operative transoesophageal echocardiogram demonstrating long-axis view of the aortic valve, aortic root abscess, and fistulous connection to the left atrium.

Figure 1

Figure 2 Pre-operative transoesophageal echocardiogram demonstrating short-axis view of the fistula in the left atrium with flow demonstrated in the fistula.