ABC | Volume 112, Nº6, June 2019

Anatomopathological Correlation Arq Bras Cardiol. 2019; 112(6):793-802 Issa and Benvenuti Pulmonary infiltrate and left ventricular apex obliteration in a young man Despite the initial diagnostic and therapeutic approach, the patient's symptoms intensified, and he once again sought medical care due to dyspnea worsening and the appearance of productive cough. On physical examination, tachycardia persisted and pulmonary crepitations with discreet edema of the legs and feet appeared. The chest X-ray, as well as the first chest tomography, suggested the presence of alveolar infiltrate. The laboratory evaluation is notable for the decrease in hemoglobin and sodium, and BNP elevation. Taken together, the clinical findings indicate that the patient had started a picture of heart failure (presence of lower limb edema, anemia – possibly dilutional – hyponatremia, elevation of BNP and distribution of infiltrate at the apices and posterior portions of the lungs, in association with right pleural effusion). Moreover, the finding of young leukocyte forms in peripheral blood, of leukocyturia, hematuria and hemoglobinuria indicate the existence of an inflammatory and/or infectious process. The presence of the association of heart failure with inflammatory signs in a patient with underlying heart disease led us to consider the possibility of infective endocarditis. The diagnosis of endocarditis is based on the presence of predisposing heart disease (more commonly a valvulopathy), findings of an inflammatory process and persistent bacteremia; from the clinical-morphological viewpoint, the characteristic lesion is of vegetation detected by the echocardiogram. Despite the findings of underlying heart disease and progressive inflammatory/ infectious process, there was no finding of vegetation by the echocardiography; additionally, the finding of Staphylococcus haemolyticus in blood culture only has diagnostic value when recovered in multiple cultures collected at different times, because it is a skin-colonizing agent. 11 Finally, it should be noted that the use of multiple antibiotic agents may reduce the chance of recovery of infectious agents in blood cultures. 12 From a clinical and epidemiological point of view, one of the main causes of infection and septicemia in patients with heart disease is pneumonia, of which clinical and radiological characteristics are compatible with the clinical evolution of the present case. As there was recent hospital admission, it is possible to consider the possibility of acquired pneumonia caused by nosocomial bacterial flora. In this regard, a study of necropsies performed in patients with heart disease found pneumonia as the most commonly found infectious diagnosis. 13 Moreover, in a study of 1,989 patients hospitalized for heart failure, the presence of pneumonia was a factor related to a worse prognosis, as was the intensity of the inflammatory process measured by the Protein C level in peripheral blood. 14 (Dr. Victor Sarli Issa) Diagnostic hypotheses: Restrictive cardiomyopathy, smoking, hypothyroidism, acute decompensated heart failure, pneumonia, multiple organ dysfunction. (Dr. Victor Sarli Issa) Necropsy The heart weighed 516 g. The cross-section of the ventricles showed marked concentric myocardial hypertrophy and fibrous obliteration of the left ventricular cavity apex (Figure 8). The hypertrophic process predominated in the apical portion, with extensive organized and organizing thrombosis, which impaired both the left ventricular inflow (Figure 9) and outflow tracts (Figure 3), leading to marked reduction in the cavity volume. There was no subaortic obstructive septal hypertrophy. In the basal portion of the inflow tract, the left ventricular free wall measured 2.0-cm thick and the ventricular septum, 2.5 cm. In the mid-apical portion the left ventricular free wall measured 2.5 cm. The mitral valve showed cusps and chordae tendineae of normal aspect, but its papillary muscles were surrounded by the ventricular cavity thrombosis (Figures 9 and 10). The histological analysis of the myocardium showed focal areas of cardiomyocyte disarray and thick‑walled arterioles in the left ventricle (Figure 11). There was irregular fibrous thickening of the tip of the endocardium Figure 8 – Cross section of the ventricles, showing the evident left ventricular concentric hypertrophy and the fibrous obliteration of the cavity apex (arrow). 799