Title : A case of amaurosis fugax, infectious or embolic?
Abstract:
The patient is a 54-year-old female with past medical history of Dilation and curettage (D&C) who presented with left sided monocular vision loss 5 months prior to admission. She was evaluated by stroke with comprehensive workup that has been negative. She obtained TTE was significant for an atrial septal aneurysm and an intra pulmonary shunt vs Patent foramen oval (PFO). Later, a TEE showed mitral valve masses involving anterior leaflet tip, PFO, Atrial septal aneurysm, and Lambl's excrescences, new from before, so patient was electively admitted for further evaluation. She was hemodynamically stable. The deferential diagnosis included infective endocarditis versus culture-negative endocarditis and non-bacterial thrombotic endocarditis (NBTE). On fundus exam, no retinal abnormalities nor optic nerve pathology were detected. Laboratory studies showed ESR, CRP and complement levels that were within normal limits, ANA, anti-Ro/anti-La were negative signifying a low concern for Libman Sachs endocarditis. TSH was within normal limits. Infectious workup revealed negative for Histoplasma Ag, HIV, Coxiella, Bartonella DNA. Blood cultures were negative for bacterial and fungal pathogens. CT, CTA, MRI and MRA of her head and neck were negative. The patient was treated with vancomycin and ceftriaxone for empiric coverage of culture negative endocarditis for 4 weeks.
Discussion: We present a case of amaurosis fugax with new mitral valve vegetations and Lambl's excrescences. There was concern for infective endocarditis given that patient described malaise, and subjective fevers since her D&C procedure a year prior to her presentation. Subjectively, the patient was afebrile and had no leukocytosis; blood cultures were negative prompting suspicions of culture-negative endocarditis. The patient was to complete antibiotics for 4 weeks, a repeat TTE 2 months after showed resolution of her vegetations. Based on the workup described above, amaurosis fugax was assumed to be caused by a cardioembolic phenomenon from either the mitral valve vegetations (culture negative infective endocarditis) or lambl's excrescence. Lambl's excrescences (LEs) are filiform valvular fronds with hypermobility [1]. These occur mostly along valve closure lines, mostly on the atrial side of the mitral valve (68-76%), followed by the aortic valve on the ventricular side (38-50%) [2]. Though largely asymptomatic, LE has been linked to thromboembolic events such as cerebrovascular accidents [3]. TEE is the gold standard for diagnosis [4]. Due to the rarity of the occurrence, definite therapeutic guidelines do not exist; nonetheless, based on isolated case reports, the various management techniques include single and dual antiplatelet therapy, anticoagulation, and surgery [5].
Conclusion: LE are rare growths on endocardial surfaces with high propensity to embolize. When associated with evidence of thromboembolic phenomena, they necessitate treatment with anti-platelets or anti-coagulants.
Audience Take Away
- The audience will be able to review the clinical course and review case progression and management.
- Patients will benefit from further management of Lamble’s excrescence if indeed it was implicated in cardio-embolic phenomenon.
- The faculty can use this case discussion and review the associated evidence, treatment with antiplatelets or anti coagulation.
- This research provides management indication from current literature to guide medical care especially for patients who have clinical presentation that was not attributed to an otherwise related etiology.
