Primary Mural Endocarditis Caused by Streptococcus pyogenes
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Primary mural endocarditis is a rare infection of the nonvalvular endocardium. It is caused by endothelial damage with seeding during bacteremia.Streptococcus pyogenes is an uncommon cause of endocarditis. Embolization, abscess, fistula, valve destruction, and perforation can occur. Echocardiography is necessary to diagnose mural endocarditis.

A 37-year-old African American man with a medical history significant for HIV/AIDS and daily cannabis use presented to the emergency department reporting severe, stabbing, midsternal chest pain that started suddenly at rest. He also reported nonadherence to antiretroviral therapy within the year. Initial electrocardiography on presentation was notable for diffuse, submillimeter ST-segment elevations in leads I, II, aVL, and V3 through V6, with nonspecific T-wave changes.

A small posterior pericardial effusion was identified on TTE, as well as echogenic structures within the left atrium adjacent to the interatrial septum as well as the right atrium along the free wall and tricuspid valve annulus.

The first two blood cultures obtained on admission grew group A Streptococcus, specifically S pyogenes, and empiric antibiotic therapy was transitioned to penicillin G. Most concerning was a solid left atrial mass along the anterior aspect of the mitral valve annulus, extending toward the interatrial septum and aortic root. The echocardiographic finding of a left atrial mass independent of the mitral valve leaflets without significant compromise of valvular function particularly increased physicians suspicion for mural endocarditis, though it was unlikely an isolated process.

The patient had symptomatic resolution on intravenous antibiotic therapy during his hospital stay, which was transitioned to ceftriaxone at discharge with a plan for completion of at least a 4-week course per infectious disease recommendations. Antiretroviral therapy was also restarted.

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