PMC9716447_01
Axial diffusion weighted imaging (DWI) demonstrated multiple punctate, T2
hyperintense foci within the centrum semiovale bilaterally, as well as the
subcortical white matter of the right frontal lobe. Corresponding
hypointense foci on apparent diffusion coefficient mapping (ADC, not shown)
confirmed restricted diffusion. In the context of the patient's known
endocarditis, these findings were concerning for septic emboli. (a) PSAX
view of aortic valve with what would be classically called moderate
paravalvular regurgitation (10-20% of circumference), (b) apical two-chamber
view of oscillating mitral valve mass, (c) apical four-chamber view showing
mobile mass on mitral valve with mitral annular calcification, and (d) two
distinct paravalvular regurgitant jets on apical windows.
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With the previous prolonged positivity of blood cultures and current suspicion for prolonged bacteremia in the absence of continued antibiotic therapy, transthoracic echocardiography (TTE) was sought and demonstrated a large mobile mass on the mitral valve and moderate-severe paravalvular prosthetic aortic regurgitation, both of which were concerning for infective endocarditis in context of persistent bacteremia (Figure 1).
Axial gradient recall echo (GRE) imaging demonstrated multiple punctate foci
of magnetic susceptibility consistent with microhemorrhages, likely
reflecting additional sequela of small emboli.
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CT of the brain or head demonstrated an evolving, subacute right posterior cerebral artery territory infarction and follow-up magnetic resonance imaging of the brain found multiple small foci of restricted diffusion suggestive of emboli (Figure 2).