Aortic valve endocarditis with root abscess causing superior
The first case of endocarditis with root abscess causing compressive superior vena cava (SVC) obstruction is reported.

An 84-year-old gentleman with previous tissue aortic valve replacement presented with fevers and systemic upset. Blood cultures grew Streptococcus anginosus and transoesophageal echocardiogram identified prosthetic valve vegetations with an associated root abscess. Antibiotics were commenced and referral made for surgical consideration. Several days into treatment the patient developed clinical signs of SVC obstruction and computed tomography demonstrated an enlarging root abscess with SVC compression.

The patient was discussed with local cardiothoracic centres, but surgery was not an option primarily due to abscess size and vascular involvement. Priority moved from active to palliative treatment given no improvement with antibiotics, unsuitability for surgery, and patient discomfort. Within several weeks, symptoms/signs of SVC obstruction actually improved, likely due to collateral venous circulation formation and the patient was discharged home with palliative care input.

There are previous reports of SVC obstruction related to infected SVC thrombus, indwelling intravascular devices, and para-aortic abscess, but none related to infective endocarditis. Streptococcus anginosus endocarditis is rare but often associated with abscess formation, and male gender, increasing age, and previous surgery are recognized risk factors.

Learning Points:
1)Superior vena cava obstruction is a rare complication of endocarditis related root abscess formation.
2)Whilst echocardiography remains the initial imaging modality of choice for endocarditis related aortic root abscess formation, multimodality imaging in the form of computed tomography compliments echocardiography in defining abscess position, size, and associated vascular involvement.

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