PMC6360552_01
Echocardiogram showing echocardiographic clips: (a) two-dimensional apical 4-chamber view showing tricuspid valve leaflet perforation (arrow) with possible chordal disruption, (b) color Doppler image of apical 4-chamber view showing tricuspid regurgitation (blue jet), (c) two-dimensional parasternal long-axis view showing tricuspid valve leaflet perforation (arrow), and (d) color Doppler image of parasternal long-axis view showing tricuspid regurgitation (blue jet).
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fig1
The transthoracic echocardiogram revealed echogenic tissues on the septal leaflet of the tricuspid valve (both on septal and anterior leaflets), tricuspid valve leaflet perforation with possible chordal disruption indicative of IE (Figure 1).
Neighbor-joining phylogenetic tree based on 2,464 unique, core genome biallelic single nucleotide (SNP) differences relative to the reference, MGAS27061, between case (circled) and CDC-sequenced emm89 iGAS strains from 2015. GAS isolates from cases of toxic shock are depicted by boxes including 2 from the 2015 CDC-sequenced strains and 2 previously described isolates from Houston, TX.
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fig2
Comparing the case isolates to recent GAS WGS performed by the Centers for Disease Control and Prevention (CDC) revealed a similar clonal relationship to nationally circulating emm89 iGAS (Figure 2). The case of pharyngeal and blood isolates did not have a unique streptococcal pyrogenic exotoxin (spe) gene content compared to non-STSS iGAS in the CDC collection and was similar to emm89 STSS strains in Houston, TX (Figure 2).