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A 53 year old woman underwent emergency laparotomy for small bowel obstruction. Inotropic support was administered via a central venous catheter. Five days postoperatively she became pyrexial, oliguric, and haemodynamically unstable. Multiple areas of peripheral limb infarction were noted. Blood cultures grew Staphylococcus aureus, which was also cultured from her central venous catheter.
Transoesophageal echo (panel A) demonstrated severe mitral and aortic valve regurgitation, a 2 cm vegetation (V) on the posterior leaflet of her mitral valve, a disorganised aortic valve (A), and echodense areas in the interventricular septum (arrows). She underwent debridement of an aortic root abscess, homograft replacement of her aortic root, and the vegetation was removed from her mitral valve via a left atriotomy. She was weaned from cardiopulmonary bypass, but died on the operating table as a result of uncontrollable haemorrhage.
Postmortem examination showed large myocardial abscesses in the left and right ventricular free wall and interventricular septum (panel B), mitral valve endocarditis, renal abscesses (panel C), and splenic and cerebral abscesses.
Multiple myocardial abscesses distant from the valvar apparatus are an uncommon, late, and usually fatal complication of endocarditis. Splenic and renal abscesses are more common. S aureus endocarditis follows a particularly virulent course, and should be treated aggressively, with surgical management considered at an early stage.
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