Streptokinase
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Blood cyst of the mitral valve: case report. A 57-year-old woman developed blood cysts of the mitral valve during treatment with streptokinase for pulmonary embolism. The woman was hospitalised with complaints of urinary symptoms, fever and abdominal pain. She had a history of nephrolithiasis, type 2 diabetes mellitus and systemic arterial hypertension. She had underwent a dental procedure for tooth decay 10 days before symptoms onset. Initially in another facility, she was treated for bacterial urinary tract infection, renal failure, pneumonia and ketoacidosis. She received unspecified carbapenems, aminopenicillins and glycopeptides following requirement of renal replacement. During her admission, she reported right calf pain, dyspnoea, palpitation and chest pain. She was suspected for pulmonary embolism. Thoracic CT angiography revealed thrombosis of both main branches and the pulmonary trunk. She underwent systemic thrombolysis with streptokinase [route and dosage not stated] for the high-risk pulmonary embolism. After that, she was received warfarin and enoxaparin sodium [enoxaparin]. After the thrombolysis, she had chest discomfort with fever despite antibiotic therapy. These finings were suggesting bacterial endocarditis or dialysis catheter-related infection. A transesophageal ECG revealed mass over mitral valve considered as bacterial vegetation. She was continued on vancomycin. Subsequently, she was transferred to ICU for a month. Her vital signs were normal but she was pale and had positive S3 sounds for cardiopulmonary auscultation. Additionally, she had anaemia 7.4 g/L, leukocytosis 13.010 cells/µL, elevated CRP 17 mg/L and mild thrombocytopenia 146.000/µL. Her renal function was severely compromised with blood uremic nitrogen 42 mg/dL and creatinine 5.3 mg/dL. Arterial blood gases demonstrated metabolic acidosis. Urine cultures was positive for azole-sensitive Candida albicans and IRT-resistant Escherichia coli. Therefore, she additionally received fluconazole. After 16 days of admission, transesophageal ECG revealed preserved ejection fraction and left ventricular dimensions. The mitral valve demonstrated 10 x 10mm round image with hyperrefringent edges and hypoechogenic content in anterior ring, corresponding to A1 and A2 segments. This lesion did not obstructed the left ventricle outflow tract nor compromise the valve function. The rest of the cavities, valves and vessels were normal but she had a small left pleural effusion. The absence of other findings and the density of mass were consistent with endocarditis. The mass was high and asynchronously mobile. All these findings confirmed the diagnosis of a blood cyst. Despite unspecified anticoagulation, the size of cyst remained same in transesophageal ECG. Being less likely that it corresponded to a thrombus adhered to the valve with no predisposing factors. The woman received 10 days treatment including unspecified antifungals. Subsequently, the inflammatory response resolved completely. The antibiotic therapy was withdrawn as bacterial endoca
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