58 year old man develops a fever and general weakness 2 weeks after visiting his dentist for removal of an infected tooth. Despite antibiotic therapy, the patient died five days later of generalized sepsis.

Observe a pre-mortem ultrasound as well as the gross and microscopic pathology of the patient's aortic valve.

How would you describe the valvular lesions? Is there inflammation, fibrin deposition, tissue destruction, bacterial colonization?

How does the history of an infected tooth fit with the patient's clinical picture now?

What might be the causative organism?

What risk factors are associated with bacterial endocarditis?

This is a case of bacterial endocarditis where the aortic valve has become colonized and invaded by bacteria leading to the formation of vegetations on the leaflets composed of thrombotic debris, bacteria, and acute inflammation. The process is often associated with destruction of the underlying valve.

Prior injury to the heart valve (e.g. calcification, stenosis) and other cardiac abnormalities (e.g. bicuspid aortic valve) that result in turbulent flow make colonization easier. Prosthetic valves are also at risk. In such cases, the less virulent Strep viridans, a part of the normal oral flora, can cause endocarditis.

Healthy valves are more commonly infected with the more virulent Staph aureus (as is the case here).

Invasive procedures leading to bacteremia (such as the extraction of an infected tooth) predispose patients to endocarditis. Patients that are immunosuppressed are also at risk.

IV drug user are more likely to get right sided disease.